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COLLEGE  OF  PHYSICIANS 
AND  SURGEONS 


Reference  Library 

Given  by 


Diseases  of  the  Heart: 

Tbeir  Diagnosis  and 
Treatment. 


By  ALBERT  ABRAMS,  A.  M.,  M.  D., 
(Heidelberg),  F.  R.M.S., 

CONSULTING  PHYSICIAN  FOR  DISEASES  OF  THE  CHEST, 

MT,  ZION  HOSPITAL  AND  THE  FRENCH  HOSPITAL, 

SAN  FRANCISCO. 


CHICAGO : 

G.  p.  ENGELHARD  &  COMPANY, 
1900. 


Copyright  1900 
By  G.  P.  ENGELHARD  &  COMPANY. 


CONTENTS. 


Chapter.  Page. 

I.     Introduction  to  Diseases  of  the  Heart.   11 

II,     The    Diagnosis    of    Diseases    of    the 

Heart 30 

III.     General  Treatment  of  Diseases  of  the 

Heart 65 

TV.     Affections  of  the  Pericardium 92 

Y.     Endocarditis    and    Chronic    Valvular 

Disease   109 

VI.     Neuroses  of  the  Heart 128 

VII.     Affections  of  the  Arteries 144 

VIII.     Addendum 155 


Digitized  by  tine  Internet  Archive 

in  2010  witii  funding  from 

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http://www.archive.org/details/diseasesofhearttOOabra 


PREFACE. 

This  little  book  was  never  intended  to  aspire 
to  the  dignity  of  a  treatise  on  diseases  of  the  heart. 
The  primary  object  was  to  make  it  useful  to  the 
practical  physician  in  the  diagnosis  of  cardiac 
diseases.  The  cardiac  diagnostician  is  often  like 
the  veterinarian,  for  his  diagnosis  is  based  essen- 
tially on  objective  signs.  He  must  depend  largely 
on  the  Baconian  or  inductive  method  of  ratiocina- 
tion, in  contradistinction  to  the  deductive  method. 

The  former  analytic  method  of  diagnosis  is  a 
conclusion  drawn  from  concrete  facts.  Mistakes  in 
diagnosis  may  be  attributed  to  the  following 
causes:  1.  Incomplete  or  careless  examination. 
2.  Misinterpretation  of  symptoms,  due  to  errors 
in  judgment.  3.  Ignorance  of  the  methods  of 
examination.  4.  Prejudiced  preconception.  5. 
Incompleteness  of  medical  diagnosis.  6.  Placing 
too  much  reliance  on  the  results  of  treatment. 
7.  Incomplete  history  of  the  case,  and  the  incom- 
plete development  of  symptoms.  8.  Simulation 
or  dissimulation  on  the  part  of  the  patient. 

1.  Errors  in  diagnosis  are  not  so  much  due  to 
ignorance  as  carelessness.  Sir  William  Savory 
tritely  remarks,  "Consciousness  of  one's  ignorance 
may  do  much  to  avert  the  errors  of  carelessness, 
and  he  who  has  confidence  in  his  own  judgment 
should  of  all  men  be  most  careful  in  inquiry." 


6  PREFACE. 

Unfortunately,  we  of  to-day  treat  the  disease,  but 
not  the  patient.  "And  I  said  of  medicine,  that  this 
is  an  art  which  considers  the  constitution  of  the 
patient,  and  has  principles  of  reason  and  action 
in  each  case."  It  is  but  a  few  years  ago,  that  a 
physician  punctured  a  pregnant  uterus  with  a  tro- 
car, believing  that  he  was  dealing  with  a  case  of 
ascites.  We  recall  the  grave  error  occurring  in  the 
practice  of  a  famous  English  surgeon  who  mistook 
a  swelling  in  the  neck  for  an  abscess,  who,  with 
more  precipitation  than  reflection,  plunged  his 
lance  into  the  tumor  and  death  from  hemorrhage 
resulted. 

2.  Under  the  caption  of  misinterpretation  of 
symptoms  due  to  errors  in  judgment,  mistakes  may 
arise  from  (a)  placing  too  much  reliance  on  the 
subjective  symptomatology;  (b)  giving  undue 
prominence  to  one  symptom  to  the  exclusion  of 
others;  (c)  grouping  symptoms  which  are  the 
effect  of  disease,  and  not  the  disease  itself.  When 
the  pathologist  makes  an  autopsy  he  records  man}' 
of  the  pathological  conditions  found,  as  anatomic 
diagnoses.  The  clinician  should  be  similarly 
guided.  It  would  appear  at  times  as  if,  in  our 
struggle  to  establish  a  diagnosis,  it  would  be  better 
to  make  none  at  all,  rather  than  group  symptoms 
under  such  equivocal  expressions  as  pseudoangina, 
arrythmia,  cardiac  palpitation,  etc.     Such  expres- 


PREFACE. 


sions  mean  practically  nothing  in  etiologic  diag- 
nosis. 

3.  Ignorance  of  the  methods  of  examination  is 
responsible  for  many  unfortunate  mistakes.  The 
rejected  applicants  of  insurance  companies  furnish 
a  large  contingent.  Nephritis  is  diagnosed  because 
albumin  is  present  in  the  urine,  diabetes,  because 
sugar  is  found,  and  heart  disease  because  murmurs 
are  heard.  An  unprincipled  physician  could  reap 
a  harvest,  by  putting  in  condition  for  re-examina- 
tion many  rejected  applicants,  diseased  or  other- 
wise, for  life  insurance. 

4.  Prejudiced  preconception  arises  from  two 
causes:  (a)  Placing  too  much  reliance  on  the 
history  of  the  patient;  (b)  being  misled  by  first 
appearances.  Like  the  critic  who  never  read  a 
book  before  he  received  it  because  he  might  be 
prejudiced,  so  it  should  be  with  the  physician — 
he  should  not  learn  the  history  of  his  patient  be- 
fore he  examines  him.  Diseases  present  such  vari- 
ous pictures,  that  with  our  mental  astigmatism, 
we  can  see  anything  we  want.  The  personal  his- 
tory of  the  patient  should  only  be  used  in  confirm- 
ing the  objective  examination. 

5.  When  a  disease  runs  a  typic  course  diagnosis 
is,  as  a  rule,  easy ;  but  when  the  affection  is  atypic, 
one  is  frequently  led  into  error.  The  physician 
is  too  often  inclined  to  misinterpret  the  limitations 
of  his  art,  mistaking  the  latter  for  his  own  delin- 


PREFACE. 


quencies.  Myocarditis  is  more  often  an  anatomic 
than  a  clinic  diagnosis.  Differentiation  between 
cardiac  dilatation  and  pericardial  effusion  is  ex- 
ceedingly difficult  at  times  and  to  puncture  the 
dilated  heart  with  the  idea  that  the  latter  condition 
is  present  is  a  gross  error.  Treatment  should  never 
be  attempted  before  a  diagnosis  is  made.  Better 
no  treatment  than  meddlesome  therapy.  Qui 
bene  dignoseit,  bene  curat.  It  is  related  of 
Frerichs,  that  after  examining  a  patient,  he  was  in 
doubt  about  the  diagnosis.  The  patient  insisting 
about  knowing  the  nature  of  his  trouble,  Frerichs 
comforted  him  with  the  assurance  that  the  diag- 
nosis would  be  determined  at  the  autopsy. 

6.  We  are  frequently  led  into  error  by  mistak- 
ing recovery  for  cure,  thereby  ignoring  the  vis 
medicatrix  naturae.  I  have  seen  many  patients 
with  organic  cardiac  murmurs,  the  latter  becom- 
ing less  intense  after  the  administration  of  chalyb- 
eates.  Under  the  circumstances,  one  would  be 
inclined  to  regard  the  murmurs  as  anemic.  Upon 
more  mature  consideration,  this  view  would  be 
dispelled.  Impoverishment  of  the  blood  attends 
nearly  all  organic  cardiac  affections  and  only  suc- 
ceeds in  intensifying  the  murmurs,  hence  iron  only 
removes  the  factor  in  intensification. 

7.  Diagnosis  must  be  held  in  abeyance  in  many 
cases  owing  to  undeveloped  symptoms  and  incom- 
plete history  of  the  case.    Problematic  diagnoses 


PREFACE.  9 

are  elusive,  and  a  diagnosis  altered  to  correspond 
with  each  stage  of  the  patient's  illness  is  no  diag- 
nosis at  all. 

8.  Disease  is  expressed  in  a  manner  peculiarly 
its  own.  The  interpretation  of  the  signs  consti- 
tutes diagnosis.  The  translation  may  be  correct, 
partially  correct,  or  wrong.  In  all  three  instances 
the  result,  as  far  as  the  patient  is  concerned,  v/ill, 
as  a  rule,  be  the  same,  provided  no  treatment  is 
instituted.  To  treat  a  disease,  other  than  by  ex- 
pectant methods,  where  the  diagnosis  is  wrong,  is 
adding  insult  to  injury. 
S.  W.  cor.  Van  Ness  Avenue  and  California  St. 

December,  1900,  San  Francisco, 


CHAPTER  I. 

IIVTRODUCTION. 

The  heart  with  its  valvular  apparatus  acts  like 
a  pump  with  a  suction  and  pressure  valve.  Dur- 
ing diastole,  it  sucks  the  blood  from  the  veins,  and 
during  systole  drives  it  into  the  arteries.  There- 
fore during  diastole  the  pressure  in  the  veins 
sinks  and  rises  in  the  arterial  system  during  di- 
astole. This  difference  in  pressure  causes  the  blood 
to  circulate. 

COMPENSATION. 

All  heart  affections,  whether  of  the  valves, 
muscle  or  pericardium,  result  in  circulatory  dis- 
turbances and  are  characterized  by  diminished 
pressure  in  the  arteries  and  increased  pres- 
sure in  the  veins,  with  retardation  of  the  blood 
current  in  the  capillaries.  When  the  heart  by  in- 
crease of  power  and  volume  opposes  the  local  and 
general  disturbances,  the  lesion  is  said  to  be  com- 
pensated, and  a  well  compensated  valvular  lesion 
may  be  unattended  by  subjective  symptoms. 

Compensation  fails  when  the  heart  muscle 
(myocardium),  in  consequence  of  nutritive  dis- 
turbances, degenerates.  A  valvular  heart  trouble, 
especially  in  children,   retards  development  and 


12  DISEASES   OF   THE   HEART. 

nutrition,  leading  to  cardiac  cachexia.  The  not- 
able tissue  changes  are  thickening  of  the  nose  and 
lips  and  clubbing  of  the  finger  ends. 

Overloading  of  the  veins  leads  to  the  accumu- 
lation of  fluid  in  the  tissues ;  beginning  first  in  the 
feet,  it  gradually  invades  the  rest  of  the  body. 
Fluid  also  accumulates  in  the  serous  cavities 
(pleura,  pericardium,  brain  ventricles).  As  a 
rule,  the  peritoneum  is  the  first  serous  cavity  in- 
vaded (ascites).  The  chief  cause  of  cardiac 
dropsy  is  disease  of  the  mitral  valve,  and  especially 
mitral  stenosis. 

Cyanosis  of  the  skin  is  an  early  sign  and  ap- 
pears as  soon  as  the  pulmonic  circulation  is  dis- 
turbed, therefore  cyanosis  is  more  evident  in  mitral 
than  in  aortic  lesions.  The  cutaneous  veins  are 
filled  with  blood  and  may  become  varicosed. 
Jaundice,  due  to  catarrh  of  the  bile  passages,  is  not 
uncommon.  CutaneoiLS  hemorrhages  from  rup- 
ture of  the  capillaries  or  caused  by  emboli  may 
develop. 

The  temperature  of  the  body  may  be  normal  or 
lowered,  owing  to  the  retarded  circulation.  Inter- 
current elevations  of  temperature  may  be  caused 
by  emboli  in  the  viscera  or  lung  infarcts. 

PULSE. 

The  pulse  has  a  specific  character  in  nearly  every 
valvular  lesion.  Disturbance  of  compensation  gives 
a  frequent,  irregular,  soft  and  feeble  pulse.      An 


INTRODUCTION.  13 

intermittent  pulse  is  caused  by  feeble  heart  con- 
tractions which  are  not  strong  enough  to  drive 
the  blood  to  the  radial  artery.  In  such  instances, 
if  the  heart  is  auscultated  synchronously  with  pal- 
pation of  the  pulse,  there  are  more  heart  tones 
than  pulse  beats. 

Palpitation  of  the  heart,  a  frequent  symptom, 
may  be  subjective,  objective,  or  both.  Pain  in  the 
precordia  radiating  to  the  left  arm,  neck  or  um- 
bilicus, gives  rise  to  symptoms  not  unlike  angina 
pectoris.  This  precordial  pain  is  especially  fre- 
quent in  aortic  incompetency  and  has  been  at- 
tributed to  irritation  of  the  cardiac  plexus  by  the 
dilated  aorta. 

BLOOD-VSSSELS. 

Emboli  and  thromboses  occur.  Emboli  from 
the  right  ventricle  pass  into  the  pulmonary  arteries 
and  cause  hemorrhagic  infarctions.  Emboli  origi- 
nating from  the  left  ventricle  go  to  the  extremi- 
ties, skin,  retina  or  the  viscera.  Embolism  of  the 
spleen  is  manifested  by  a  sudden  chill,  fever,  per- 
spiration, pain  in  the  splenic  region  and  enlarge- 
ment of  that  viscus. 

To  the  foregoing  symptoms,  hematuria  is  added 
when  the  embolus  attains  the  kidney.  An  embolus 
of  the  brain  reaches  that  organ  usually  through 
the  left  carotid  artery. 

LUNGS. 

Dyspnea,  especially  on  exertion,  is  frequent. 
The  dyspnea  of  heart  disease  is  out  of  all  proper- 


14  DISEASES   OF  THE  HEART. 

tion  to  the  physical  changes  in  the  lungs.  Diffi- 
cult breathing  is  usually  caused  by  pressure  of  the 
enlarged  heart  on  the  lungs,  disturbed  pulmonic 
circulation,  hydrothorax,  ascites  or  bronchial 
catarrh. 

Hemoptysis  occurs  frequently  in  mitral  disease. 
Hemorrhage  may  be  due  to  congestion,  rupture  of 
vessels  or  hemorrhagic  infarcts.  Hemoptysis  is 
most  frequently  the  result  of  infarcts,  and  the 
latter  are  frequent  in  aortic  disease.  Lung  in- 
farcts lead  to  a  brownish  red  sputum  not  unlike 
that  of  pneumonia.  Stress  has  been  laid  on  the 
fact  that  in  hemoptysis  of  cardiac  origin,  the  blood 
is  clotty  and  blackish  blue  in  color. 

Edema  of  the  lungs  is  a  frequent  cause  of  death. 
It  gives  rise  to  diffuse  crepitant  rales  and  serous 
expectoration.  Valvular  heart  troubles  predispose 
to  inflammatory  lung  affections.  Glottis  edema 
may  complicate  heart  lesions.  Epistaxis  is  not 
infrequent. 

GASTKECTATIC    DYSPNEA. 

A  freqiient  cause  of  dyspnea  in  heart  disease  is 
acute  dilatation  of  the  stomach.  After  meals 
patients  complain  of  difficult  breathing  and  dis- 
tress in  the  precordia,  and  death  has  not  unfre- 
quently  followed  an  indigestible  meal.  I  have 
called  this  condition  gastrectatic  dyspnea,  because 
it  is  always  associated  with  a  dilated  stomach.  In 
some  instances  dyspnea  is  associated  with  symp- 


lNTkot>tJctioN.  15 

toms  of  angina  pectoris.  Many  patients  make 
no  mention  of  dyspeptic  symptoms.  They  com- 
plain of  pressure  or  weight  in  the  sternal  or  pre- 
cordial region^  and  often  add  that  ernctation  will 
relieve  the  pressure.  This  symptom,  as  I  have 
assured  myself  after  examination  of  a  number  of 
cases,  is  dislocation  of  the  heart  upwards  by  an 
acute  or  chronically  dilated  stomach.  Some  years 
ago  I  reported  a  case  of  gastroptosis  and  merycis- 
mus,  with  voluntary  dislocation  of  the  stomach 
and  kidneys.*  This  phenomenal  case  taught  me  one 
fact  in  particular,  how  easily  the  heart  could  be 
displaced  by  dilatation  of  the  stomach.  The  in- 
dividual in  question  could,  by  buccal  insufflation 
of  the  stomach,  cause  his  heart  to  disappear  be- 
hind the  lungs,  so  that  percussion  of  the  pre- 
cordial region  yielded  no  dullness  on  percussion. 
This  case  directed  my  attention  to  a  correct 
investigation  of  all  individuals  presenting  them- 
selves for  the  treatment  of  slight  dyspeptic  symp- 
toms in  whom  sternal  pressure  was  the  chief 
subjective  symptom. 

In  all  such  cases  the  diminished  area  of  cardiac 
dullness  bears  a  distinct  relation  to  the  severity  of 
the  pressure  symptoms.  The  removal  of  ingesta 
and  gases  from  the  stomach  restores  the  heart  to 
its  normal  position  and  feeble  heart  tones  become 
strong. 

*Medical  News,  April  13,  1895. 


16 


DISEASES   OF   THE   HEART. 


Not  infrequently  true  astlimatic  attacks,  asthma 
dyspepticum,  were  present.  The  patient  is  unable 
to  get  rid  of  the  gases  owing  to  a  spasm  of  the 


Fig.  I — Skiascopic  picture  of  the  outline  of  the  heart 
and  stomach  before  swallowing  the  seidlitz  powder. 

sphincters  of  the  stomach;  the  distended  stomach 
pushes  the  diaphragm  upward,  dislocating  the 
heart,  and  induces  typical  attacks  of  asthma. 


INTRODUCTION.  17 

To  quickly  detect  a  dilated  stomach  encroach- 
ing on  the  chest  organs,  the  following  percussion 
method  will  be  found  practical.  The  circular 
tympanitic  stomach-lung  region  formed  by  the 
stomach  beneath  the  lower  lobe  of  the  left  lung 
gradually  disappears  behind  the  axillary  line  if 
the  stomach  is  normal,  but  if  dilated,  the  tympan- 
itic sound  may  be  traced  to  the  vertebral  column. 
Sometimes  in  dyspeptic  asthma  relief  is  quickly 
obtained  by  introduction  of  the  stomach  tube  and 
allowing  the  gases  to  escape.  The  following  il- 
lustrations describe  more  fully  than  words  the 
influence  of  a  dilated  stomach  on  the  position  of 
the  heart.  They  are  rough  reproductions  from  the 
fluoroscopic  picture  with  the  use  of  the  X-rays. 
In  the  average  examination  of  the  chest  by  the 
X-rays,  the  portion  of  the  stomach  which  is  in 
direct  contact  with  the  chest  wall  is  obscured  by 
the  shadow  cast  by  the  spleen,  but  in  this  patient 
no  spleen  shadow  being  present  and  the  contour 
of  the  stomach  being  clearly  defined,  opportunity 
was  afforded  to  test  the  influence  of  a  stomach 
distended  by  a  seidlitz  powder  on  the  position  of 
the  heart.*  Every  phase  of  the  stomach  distention 
was  followed  in  the  fluoroscopic  picture. 


*Later  a  similar  case  came  under  my  observation. 
See  "Note  on  a  Case  of  Nervous  Eructations  Studied 
by   Skiagrams,"   Philadelphia   Med.  Journal,   Aug.    12, 


li 


18 


DISEASES    OF   THE   HEART. 


CAKDIAC    ASTHMA. 

Cardiac  Asthma  closely  simulates  bronchial 
asthma,  but  the  former  is  associated  with  some 
anomaly  of  the  heart  or  arterial  system.  If  such 


Fig.  2 — Shows  the  same  organs  after  distention  of 
the  stomach  by  gas. 

anomalies  exist,  asthmatic  paroxysms  may  result, 
whenever  the  pressure  in  the  capillaries  of  the 
lungs  rises.     Such  rise  in  pressure  may  follow  an 


INTRODUCTION. 


19 


increased  or  diminished  blood  pressure  in  the 
aorta.  In  either  instance^  the  capillaries  of  the  lung 
alveoli  become  surcharged  with  blood,  which  in 
turn  make  the  alveolar  walls  rigid  and  incapable  of 
distension,  thus  diminishing  the  respiratory  area. 
The  following  table  may  assist  in  differential  diag- 
nosis : 

BRONCHIAL  ASTHMA. 
Usually  absent. 

Dyspnea  is  expiratory. 


CARDIAC   ASTHMA. 

Signs  of  cardiac  disease 
(valvular  lesion,  arterio 
sclerosis,  fatty  heart). 

Dyspnea  is  equally  in- 
spiratory and  expira- 
tory. 

Pulse  in  the  early  stage 
of  paroxysm  may  be 
strong,  but  it  soon  be- 
comes soft  and  small. 

Percussion  shows  an  ex- 
tension of  the  borders, 
of  the  lungs  and  oblit- 
eration of  the  area  of 
superficial  cardiac  dull- 
ness. 

Auscultation  shows  an  ab- 
scence  of  rales  unless 
complicated  by  edema 
of  the  lungs. 


The  pulse  is  usually  one 
of  increased  tension 
throughout  the  par- 
oxysm. 

The  extension  of  the  lung 
borders  is  more  pro- 
nounced than  in  cardiac 
asthma. 


Sonorous  and  sibilant 
rales  are  always  heard, 
louder  during  expira- 
tion than  inspiration. 


DIGESTIVE  APPARATUS. 


Venous  stagnation  conduces  to  chronic  catarrh 
of  the  gastro-intestinal  mucous  membrane,  re- 
sulting in  dyspepsia,  constipation,  diarrhea    and 


30  '  DISEASES   OF   THE   HEART, 

hemorrhoids.  Gastralgia  occurring  in  cardiac 
lesions  jnay  mislead  the  physician  if  the  diagnosis 
is  of  a  stomach  trouble. 

LIVER  AND   SPLEEN". 

The  liver  participates  early  in  the  circulatory 
disturbances.  Owing  to  the  venous  engorgement 
of  the  inferior  cava,  the  hepatic  veins  cannot  un- 
load, and  the  liver  in  consequence  swells  and  may 
be  felt  below  the  border  of  the  ribs  as  a  hard  and 
painless  mass.  Later  in  the  disease,  owing  to 
atrophy  of  the  liver  cells,  the  organ  may  become 
reduced  in  size.  Not  infrequently  the  enlarged 
liver  may  pulsate  owing  to  transmitted  pulsations 
from  the  aorta.  It  is  well  to  remember  that  the 
knee-elbow  position  will  usually  cause  the  disap- 
pearance of  transmitted  pulsations.  Stagnation  of 
blood  in  the  portal  circulation  leads  to  venous  en- 
gorgement of  the  spleen,  stomach  and  intestines, 
with  enlargement  of  the  first  mentioned  viscus. 

KIDNEYS. 

From  the  quantity  and  constituents  of  the  urine 
the  severity  of  the  compensation  failure  may  be 
gauged.  The  lower  the  blood  pressure  in  the  aorta 
and  the  higher  the  blood  pressure  in  the  venae 
cavse,  the  more  the  urine  partakes  of  the  charac- 
teristics of  passive  congestion  of  the  kidneys.  The 
urine  is  reduced,  of  high  specific  gravity,  contains 
albumin,  casts,  and  often  blood  corpuscles.    Uric 


INTRODUCTION.  21 

acid  is  increased  and  is  deposited  as  a  brick  dust 
sediment. 

NERVOUS  SYSTEM, 

Aortic  lesions,  particularly  owing  to  brain 
anemia,  are  often  complicated  by  syncopal  attacks. 
Brain  li3qDeremia  complicating  heart  lesions  is 
characterized  by  attacks  of  fainting,  fullness  in  the 
head,  ringing  in  the  ears,  etc.  Nitrite  of  amyl 
inhalations  are  of  signal  advantage  in  diagnosis. 
This  drug  will  ameliorate  symptoms  of  brain 
anemia  and  intensify  those  of  hyperemic  origin. 
An  embolus  in  the  left  arteria  fossae  sylvii  will 
cause  hemiplegia  on  the  right  side,  associated  with 
aphasia.  Temporary  aphasia  may  occur  without 
an  embolus  and  must  often  be  attributed  to  mere 
circulatory  disturbances.  Mental  diseases  are  not 
frequent  in  heart  lesions.  In  some  cases  a  real 
intellectual  disturbance  exists.  Observations  are 
recorded  of  maniacal  delirium  in  patients  with 
mitral  lesions.  Such  cerebral  troubles  may  be 
remedied  by  treatment  directed  exclusively  to  the 
heart. 

RELATION    OF   DISEASES    OF   THE   HEART   TO    OTHER 
DISEASES. 

An  individual  with  a  heart  lesion  assumes  a 
grave  risk  when  attacked  by  other  diseases.  This 
is  notably  the  case  in  febrile  affections.  In  fever, 
the  organs  show  cloudy  swelling;  a  like  change 
occurs  in  the  muscles,  and  the  heart  manifests  the 


23  DISEASES   OF   THE   HEART. 

granular  alteration  of  its  fibres  to  the  highest  de- 
gree. These  tissue  changes  arise  from  contact  with 
the  poisons  circulating  in  the  blood  and  from  the 
accompanying  rise  of  temperature  associated  with 
disturbances  of  nutrition.  A  febrile  affection 
therefore  may  seriously  implicate  the  functions  of 
the  heart  in  valvular  lesions. 

Intercurrent  diseases  of  the  lungs  tax  the  func- 
tions of  the  right  heart  to  the  utmost. 

Pregnancy  always  causes  hypertrophy  of  the 
heart,  but  this  recedes  in  the  healthy  woman  after 
delivery.  Cardiopathic  patients  are  predisposed 
to  acute  exacerbations  of  endocarditis,  and  a  large 
number  are  always  in  danger  of  miscarriage.  Du- 
rosier  noted  that  out  of  forty  children  born  of 
cardiopathic  mothers,  thirty-seven  died  before  at- 
taining the  age  of  six  years.  The  most  unfavor- 
able lesion  to  the  mother  from  the  point  of  prog- 
nosis is  mitral  insufficiency,  the  mildest,  aortic 
insufficiency.  The  most  serious  complications,  and 
the  greatest  danger  of  death  for  the  mother,  ap- 
pear about  the  seventh  and  a  half,  or  the  eighth 
month.  Cardiopathic  mothers  should  not  nurse 
their  infants  because  lactation  augments  heart 
hypertrophy. 

Endocarditis  is  regarded  by  some  as  the  cause 
of  chorea;  particles  of  fibrin  are  supposed  to  pass 
from  the  valves  as  emboli  to  the  cerebral  vessels. 
At  any  rate,  endocarditis  is  very  common  as  a 


INTRODUCTION,  23 

complication,  although  many  of  the  heart  mur- 
murs in  chorea  may  be  caused  by  anemia  or  the 
rapidly  acting  heart. 

The  belief  was  at  one  time  current  that  an  in- 
dividual with  heart  disease  was  in  no  danger  of 
contracting  phthisis.  As  a  rule  (pulmonary  ste- 
nosis the  esception),  pulmonary  tuberculosis  rarely 
develops  in  an  individual  with  a  valvular  heart 
lesion.  In  277  autopsies  on  individuals  who  dur- 
ing life  suffered  from  valvular  trouble,  Frommalt 
found  phthisical  lung  changes  in  8  per  cent  of  the 
cases.  These  statistics  show  the  infrequency  of 
phthisis  complicating  valvular  lesions,  since  Biggs 
reports  that  more  than  60  per  cent  of  his  autopsies 
showed  lesions  of  pulmonary  tuberculosis, 

ETIOLOGY  OF  DISEASES  OF  THE  HEART. 

Endocarditis  is  the  usual  cause  of  valvular  heart 
lesions.  That  part  of  the  endocardium  performing 
the  most  work  is  the  first  to  become  involved  and 
suffer  most.  This  explains  the  rarity  of  endo- 
carditis on  the  right  side  in  adults  and  the  infre- 
quencv  of  congenital  lesions  on  the  left  side  of  the 
heart.  The  process  usually  implicates  the  valvular 
endocardium  and  is  therefore  known  as  valvular 
endocarditis.  In  adult  life,  about  one-half  the 
cases  of  endocarditis  occur  on  the  mitral  valves; 
of  the  remaining  50  per  cent,  about  94  per  cent 
occur  on  the  aortic  valves ;  the  remaining  cases  are 
divided  between  the  valves  of  the  right  side,  .the 


34  DISEASES   OF   THE   HEART. 

tricuspid  valve  being  in  the  ascendency.  It  is 
customary  to  speak  of  the  following  forms  of  endo- 
carditis : 

(a)  Acute  I  ^"7^^-  ' 

(  malignant, 

(b)  Chronic  or  indurative. 

(a)  The  acute  simple  endocarditis  is  caused  by 
acute  articular  rheumatism  in  20  per  cent  of  the 
cases.  Among  the  other  causes  are :  the  infectious 
diseases  of  children,  tonsillitis  (by  many  regarded 
as  the  avenue  of  rheumatic  infection),  pneumonia, 
and  diseases  associated  with  blood  intoxications, 
like  diabetes,  gout,  cancer,  and  nephritis,  especially 
the  interstitial  form.  Various  organisms,  like 
strepto-  and  staphylococci,  gonococcus,  and  even 
the  bacillus  tuberculosis,  have  been  found  in  and 
on  the  affected  valves,  but  their  casual  relationship 
has  not  been  demonstrated. 

The  malignant  form  is  of  microbic  origin  and 
is  secondary  to  some  infectious  disease.  The  ma- 
jority of  cases  develop  during  an  attack  of  croupous 
pneumonia.  The  other  diseases  associated  with 
the  infectious  process  are:  pyemia,  septicemia, 
puerperal  fever,  gonorrhea,  erysipelas,  puerperal 
fever,  diphtheria  and  rheumatism. 

(b)  Chronic  endocarditis  results  from  the  acute 
forms  and  from  syphilis,  alcoholism,  gout  and  ex- 
cessive work  for  any  one  valve. 


INTRODUCTION.  26 

RESULTS   OF  ENDOCARDITIS. 

When  restitution  of  the  valve  does  not  take  place 
(rare),  one  of  two  conditions  of  clinical  import- 
ance occurs,  narrowing,  obstruction  or  stenosis,  or 
insufficiency  or  incompetency  of  the  valves.  In 
either  instance,  murmurs  are  heard  resulting  from 
obstruction  to  the  onward  flow  of  the  blood  or  from 
leakage  backwards  through  a  closed  but  incompe- 
tent valve.  The  former  are  known  as  obstructive, 
the  latter  as  regurgitant  murmurs. 

RESULTS  TO  THE  HEART. 

The  inevitable  consequence  to  the  heart  in  a 
valvular  lesion  is  increased  work,  leading  to  hyper- 
trophy or  dilatation. 

Hypertrophy  is  muscular  thickening  of  the  walls 
of  one  or  more  cavities  of  the  heart,  and  rarely 
occurs  without  some  dilatation  of  the  cavities. 
Increased  work  of  the  heart,  when  nutrition  is 
plentiful,  is  followed  by  hypertrophy.  Overwork, 
beyond  the  nutrition  and  muscular  power  of  the 
heart,  results  in  dilatation.  Hypertrophy  is  a 
favorable  compensatory  condition  in  cardiac  les- 
ions ;  it  is  the  response  of  the  cardiac  muscle  to  an 
increased  demand  for  power.  It  can  only  develop 
when  the  health  of  the  organism  is  maintained  at 
the  proper  standard,  and  when  this  fails  the  com- 
pensation attempted  by  nature  must  fail^  and  then 
hypertrophy  passes  into  dilatation. 

Fleart  strain  is  a  prolific  etiologic  factor  in  dis- 


26  DISEASES   OF  THE  HEART. 

eases  of  this  organ  and  of  the  aorta.  The  initial 
effect  of  prolonged  exertion  is  dilatation  of  the 
right  side  of  the  heart.  The  effect  of  sudden  strain 
is  on  the  aortic  area.  Peacock  found,  in  17  cases 
of  rupture  of  the  heart  valves  after  sudden  strain, 
that  the  aortic  valves  were  implicated  ten  times, 
mitral  valves  four  times,  and  the  tricuspid  valves 
three  times.  Schott*  has  demonstrated  in  a  series 
of  skiagraphs  that  dilatation  of  the  heart  after 
wrestling  can  be  demonstrated  by  the  Eoentgen 
rays. 

In  recent  years,  heart  disease,  resulting  from 
overstrain  after  bicycling,  has  been  frequently  ob- 
served. I  have  examined  a  few  individuals  with 
the  X-rays  who  have  done  "century  runs,"  and 
have  demonstrated  dilatation  of  the  right  heart 
following  such  foolhardy  attempts.  I  have  per- 
sonal knowledge  of  five  individuals  who  have  be- 
come heart  cripples  from  excessive  bicycling. 

The  size  of  the  heart  chambers  varies  in  health. 
In  severe  exertion  the  chambers  dilate,  especially 
those  of  the  right  side,  to  accommodate  themselves 
to  the  increased  quantity  of  blood;  this  compen- 
sation on  the  part  of  the  heart  is  "the  getting  of 
wind,"  as  it  is  called  in  training.  When  an  indi- 
vidual in  poor  condition  subjects  himself  to  heart 
strain  he  suffers  from  rapid  and  feeble  pulse,  car- 
diac dyspnea  and  precordial  pain,  and  for  months 


*Medical  Record,  March  26,  i^ 


INTRODUCTION.  27 

after  he  may  be  unfitted  for  severe  exertion  or  be- 
came permanently  crippled.  Systematic  and 
judicious  muscular  exercise  develops  heart  hyper- 
trophy, a  propitious  condition  when  great  en- 
durance is  demanded.  Injudicious  exercise  weak- 
ens the  heart. 

Relative  valvular  insufficiency  (i.  e.,  normal 
valves  which  are  no  longer  capable  of  completely 
closing  the  orifices  of  the  heart),  especially  of  the 
tricuspid  valves,  frequently  follows  heart  strain. 
In  men  the  aortic  valves  are  more  frequently  impli- 
cated than  in  women.  This  is  owing,  no  doubt, 
to  the  fact  that  bodily  exertion  predisposes  to 
arterial  disease.  Among  the  laboring  classes  valv- 
ular lesions  are  most  frequent. 

PEEQUENCY   OF  INDIVIDUAL  VALVULAR  LESIONS. 

In  extra-uterine  life  the  most  frequent  valvular 
lesion  is  mitral  insufficiency,  then  follows  mitral 
stenosis,  combined  with  mitral  insufficiency,  then 
aortic  insufficiency,  then  aortic  stenosis,  and  finally 
aortic  stenosis  combined  with  aortic  insufficiency. 
Combined  lesions  are  not  infrequent.  Mitral  and 
aortic  lesions  may  coexist  and  less  often  mitral 
and  tricuspid  lesions.  In  children,  the  most  com- 
mon combination  is  aortic  and  mitral  insufficiency. 

PROGNOSIS  OF  DISEASES  OF  THE  HEART. 

The  prognosis  in  valvular  lesions  is  unfavorable. 
Cure  may  be  spontaneous,  but  is  never  attained  by 


28  DISEASES   OF  THE   HEART, 

medication.  Aortic  are  more  favorable  than  other 
lesions,  owing  to  the  ability  of  the  voluminous 
left  ventricle  to  compensate  the  defect.  Pulmo- 
nary lesions  are  especially  unfavorable,  owing  to 
the  frequency  of  phthisis  complicating  such 
lesions.  Combined  lesions  of  different  valves  are 
more  unfavorable  than  lesions  of  individual  valves, 
owing  to  the  increased  work  thrown  on  the  heart. 
The  social  position  of  the  patient  influences  the 
prognosis.  Occupation  which  demands  little  mus- 
cular effort  and  permits  a  sedentary  life  favors 
longevity.  The  stronger  the  constitution  the 
greater  the  likelihood  of  the  heart  being  able  to 
meet  the  increased  demands  made  on  its  power. 
Valvular  lesions  acquired  in  childhood  soon  result 
in  compensatory  disturbances. 

Mechanical  troubles  of  circulation  when  the 
heart  muscle  is  inadequate  to  perform  its  task 
furnish  an  unfavorable  prognosis  and  lead  to  a 
lingering  illness,  death  resulting  eventually  from 
paralysis  of  the  heart,  blocking  of  one  of  the 
branches  of  the  coronary  arteries,  lung  edema  or 
debility.  In  other  instances  death  is  sudden  from 
heart  rupture  or  cerebral  complications.  So  long 
as  an  efficient  compensation  is  maintained  in  val- 
vular disease,  even  the  most  serious  valve  lesion  is 
unattended  by  inconvenience  to  the  patient.  Sir 
Andrew  Clark  summarized  the  following  condi- 
tions which  justified  a  favorable  prognosis :   Good 


INTRODUCTION.  29 

general  health;  just  habits  of  living;  no  excep- 
tional liability  to  rheumatic  or  catarrhal  affec- 
tions; origin  of  the  valvular  lesion  independently 
of  degeneration;  existence  of  the  valvular  lesion 
without  change  for  over  three  years;  sound 
ventricles,  of  moderate  frequency  and  general  reg- 
ularity of  action;  sound  arteries,  with  a  normal 
amount  of  blood  and  tension  in  the  smaller  ves- 
sels; free  course  of  blood  through  the  cervical 
veins;  and  lastly,  freedom  from  pulmonary 
hepatic  and  renal  congestion. 


CHAPTER  II. 

THE  DIAGNOSIS  OF  DISEASES  OF 
THE  HEART. 

SIGNIFICANCE  OF  MUEMUES. 

No  fallacy  in  medicine  has  been  more  carefully 
nourished  than  the  belief  that  a  cardiac  murmur 
is  always  indicative  of  heart  disease.  Some  of 
the  most  serious  heart  affections  are  unaccom- 
panied by  murmurs.  "The  idea  that  a  murmur 
in  itself  and  by  itself  is  a  serious  thing  dies 
hard"  (Shattuck).  Sir  Andrew  Clark  gave  utter- 
ance to  the  truism  "that  a  murmur  in  itself  is  of 
little  or  no  moment  in  determining  the  prognosis 
of  any  given  case.  Osier  voices  the  opinion  of  the 
skilled  cardiac  diagnostician  as  follows:  "Prac- 
titioners who  are  not  adepts  in  auscultation  and 
feel  unable  to  estimate  the  value  of  the  various 
heart  murmurs  should  remember  that  the  best 
judgment  of  the  conditions  may  be  gathered  from 
inspection  and  palpation.  With  an  apex  beat  in 
the  normal  situation  and  regular  in  rhythm,  the 
auscultatory  phenomena  may  be  practically  disre- 
garded." THE  APEX  BEAT. 

We  must  always  remember  that  disease  of  the 
heart  valves  of  any  consequence  to  the  patient, 


DIAGNOSIS   OF   DISEASES   OF  THE  HEART.  31 

always  leads  to  functional  and  structural  heart 
changes  and  unless  the  latter  can  be  demonstrated, 
the  diagnosis  of  valvular  disease  should  be  held 
in  abeyance.  Fowler  is  responsible  for  the  epi- 
gram: "That  the  position  of  the  cardiac  apex  is 
the  key  to  the  diagnosis  of  nearly  all  affections  of 
the  chest  and  heart." 

The  normal  location  of  the  apex  beat  excludes 
dilatation,  hypertrophy,  pericardial  effusion  and 
heart  dislocation. 

CARDIAC    MURMURS. 

Adventitious  sounds  originating  in  the  peri- 
cardium heart  and  blood  vessels  are  known  as 
murmurs.  The  auscultation  of  a  murmur  sug- 
gests- many  problems  in  diagnosis.  Having  de- 
termined the  presence  of  a  murmur  the  first  prob- 
lem to  unravel  is  its  origin.  The  most  frequent 
murmurs  are  endocardial  in  origin  and  they  are 
divided  into  organic  (if  caused  by  anatomic 
changes  of  the  heart  or  blood  vessels)  and  inor- 
ganic or  functional  murmurs  (caused  by  changes 
in  the  quality  of  the  blood.  An  organic  murmur 
may  be  obstructive  or  regurgitant.  Two  prob- 
lems await  solution:  First,  the  seat  of  the  mur- 
mur;   second,  the  nature  of  the  murmur. 

The  seat  of  the  murmur  is  determined  by  noting 
its  position  of  maximum  intensity  and  the  direc- 
tion of  its  transmission.  These  facts  apprise  us 
of  the  valve  orifice  affected. 


32  DISEASES   OF  THE   HEART. 

THE  OEIFICE  AFFECTED. 

The  position  of  maximum  intensity  of  a  mur- 
mur usually  occurs  at  the  point  where  the  normal 
valve  sound  is  best  heard  in  health.  We  must  not 
forget  that  the  heart  orifices  are  closely  situated 
and  therefore  murmurs  are  created  within  a  lim- 
ited area;  if  it  were  not  for  the  fact  that  mur- 
murs have  directions  of  selective  propagation  it 
would  be  impossible  to  determine  at  which  valve 
orifice  the  murmur  was  generated. 

DIRECTION   OF  TRANSMISSION^  NATURE  AND  TIME. 

In  general,  systolic  murmurs  of  aortic  origin  are 
transmitted  upwards  from  the  base.  Systolic  mur- 
murs of  mitral  origin  are  transmitted  toward  the 
axilla.  The  transmission  of  a  murmur  is  in  the 
direction  of  the  currents  which  produce  them. 

Our  next  duty  is  to  determine  the  nature  of  the 
murmur,  which  is  ascertained  by  noting  the  time 
of  the  murmur  and  the  direction  of  its  propaga- 
tion. Organic  endocardial  murmurs  may  be  ob- 
structive when  there  is  obstruction  to  the  onward 
flow  of  blood,  the  nature  of  the  lesion  being  a 
stenosis  and  regurgitant  murmurs  when  there  is 
leakage  backwards  through  a  closed  but  incompe- 
tent valve,  the  nature  of  the  lesion  being  an  in- 
sufliciency. 

Organic  heart  murmurs  have  a  definite  relation 
to  the  cardiac  cycle  and  we  distinguish  systolic, 
diastolic  and  presystolic  murmurs. 


DIAGNOSIS   OF   DISEASES   OF  THE   HEART.  33 

SYSTOLIC  MURMURS. 

The  systolic  murmurs  arise  from  aortic  ob- 
struction, and  mitral  and  tricuspid  regurgitation. 
Systolic  murmurs  are  synchronous  with  the  caro- 
tid pulse,  therefore  in  a  rapidly  acting  heart,  the 
time  of  the  murmur  may  be  determined  by  pal- 
pation of  the  carotid  pulse  during  auscultation. 
The  radial  pulse  should  not  be  selected  because  it 
is  felt  too  long  a  time  after  systole. 

The  diastolic  murmurs  are  aortic  regurgitation, 
and  mitral  obstruction.  The  so-called  presystolic 
murmur  is  associated  with  mitral  stenosis:  it 
occurs  at  the  end  of  systole,  or,  in  case  it  is  pres- 
ent at  the  beginning  of  diastole,  it  becomes 
stronger  toward  the  end. 

CHARACTER  OF  MURMURS. 

Eegurgitant  murmurs  as  a  rule  are  soft  and 
blowing.  The  murmur  of  aortic  regurgitation  is 
characterized  by  length  and  softness,  while  the 
murmur  of  mitral  regurgitation  is  louder,  but  not 
so  long.  Murmurs  that  are  rough  and  high  in 
pitch  are  usually  generated  by  valves  which  are 
thickened  and  rigid,  a  common  condition  in 
chronic  endocarditis.  Murmurs  soft  and  low  in 
pitch  are  associated  with  soft  exudations  on  the 
valves  and  are  heard  in  endocarditis  of  rheumatic 
origin.  The  murmur  of  mitral  obstruction  is  the 
only  murmur  which  has  a  specific  character.    It 


34  DISEASES   OF  THE  HEART. 

is  a  prolonged  nmrmur  of  a  churning  or  grinding 
character  as  if  fluid  were  being  forced  with  great 
effort  through  a  narrow  channel. 

Murmurs  may  sometimes  be  felt  in  the  heart 
region.  The  sensation  is  similar  to  that  perceived 
upon  stroking  the  back  of  a  purring  cat ;  for  this 
reason,  they  are  called  purring  tremors.  Like  mur- 
murs, they  may  be  presystolic,  systolic,  or  diastolic 
in  time.  They  are  nearly  always  indicative  of  a 
valvular  lesion. 

SECONDAEY  EFFECT  OF  VALVE  LESIONS. 

Having  ascertained  the  endocardial  character  of 
the  murmur  and  the  seat  of  the  lesion  our  next 
endeavor  is  to  confirm  our  diagnosis  by  determin- 
ing the  all  important  fact,  viz. :  the  secondary 
effect  of  the  lesion  on  the  heart.  Without  this 
corroboration  the  detection  of  a  murmur  is  with- 
out diagnostic  or  prognostic  importance. 

Aortic  Obstruction. — Owing  to  the  obstruction 
of  blood  from  the  left  ventricle,  the  latter  must 
work  with  increased  force,  therefore  it  hyper- 
trophies. Less  blood  on  account  of  the  stenosis  is 
thrown  into  the  arterial  system,  hence  the  pulse 
is  small  and  of  high  tension  owing  to  the  hyper- 
trophied  left  ventricle.  Aortic  Regurgitation. — 
The  blood  flowing  back  into  the  left  ventricle  dur- 
ing diastole,  causes  this  chamber  of  the  heart  to 
enlarge  (dilatation),  but  compensation  occurring, 
the  dilatation  is  overcome  by  hypertrophy  of  the 


DIAGNOSIS   OF  DISEASES   OF  THE  HEART.  35 

ventricle.  The  pulse  of  aortic  regurgitation  is 
pathognomonic.  It  is  called  the  Corrigan  or  "wa- 
ter hammer  pulse."  The  impression  received  by 
the  finger  on  the  radial  artery  is  one  of  recedence 


Fig.  3 — Auscultatory  areas  of  the  valves  and  points 
of  maximum  intensity  of  the  murmurs:  M,  mitral 
valve;  T,  tricuspid;  P,  pulmonary;  A,  aortic.  Ana- 
tomic position  of  the  cardiac  valves:  t,  tricuspid;  m, 
mitral;   a,  aortic;   p,  pulmonary. 

of  the  pulse  wave  as  soon  as  it  strikes  the  finger. 
The  phenomenon  is  accentuated  if  the  arm  is 
raised. 


36  DISEASES    OF   THE   HEART. 

Mitral  Regurgitation. — In  this  lesion  the  brunt 
of  the  work  is  thrown  on  the  right  ventricle,  which 
dilates  and  hypertrophies.  The  increased  tension 
of  the  pulmonary  artery  is  evidenced  by  accentu- 
ation of  the  second  pulmonic  tone.  The  arterial 
system  receives  less  blood  leading  to  insufficient 
nourishment  of  the  heart  through  the  coronary 
arteries,  hence  degeneration  of  the  organ  must 
ensue. 

In  Mitral  Obstruction  it  is  the  left  auricle 
which  primarily  hypertrophies  to  overcome  the 
narrowed  mitral  orifice.  Later,  the  right  ventricle 
hypertrophies. 

ACCIDENTAL  HEART  MUEMURS. 

There  are  a  number  of  accidental  heart  mur- 
murs, functional  in  their  nature,  which  admit 
of  no  definite  classification.  As  a  rule,  they  are 
unattended  by  any  palpable  changes  in  the  heart 
or  pulse.  They  are  almost  invariably  systolic  in 
time.  In  my  experience,  they  are  frequent  before 
operations  and  in  gastric  disturbances.  There  are 
many  individuals,  chiefly  women  in  whom  func- 
tional murmurs  appear  just  before  an  expected 
operation  and  disappear  with  equal  readiness  a 
few  days  after  the  operation.  They  might  correct- 
ly be  called  "murmurs  of  apprehension/' 

The  other  class  of  murmurs  associated  with 
stomach  disturbances,  which  for  purposes  of  con- 


DIAGNOSIS   OF   DISEASES   OF   THE   HEART.  37 

venience  I  will  designate  as  "murmurs  of  gastric 
origin,"  I  have  encountered  frequently.  They 
usually  coexist  with  digestive  disturbances  and  are 
sometimes  of  great  intensity.  Such  individuals 
complain  of  precardial  pain  and  pressure  and  the 
disappearance  of  the  latter  symptoms  mark  the 
evanescence  of  the  heart  murmurs.  The  mur- 
murs are  in  no  wise  associated  with  the  pressure 
of  a  dilated  stomach  on  the  heart  as  would  be 
primarily  surmised,  for  I  have  never  been  able  in 
such  individuals  after  disappearance  of  the  mur- 
murs to  recreate  them  by  artificial  insufflation  of 
the  stomach.  Other  causes  must  exist  and  the  most 
likely  cause  is  reflex  irritation  of  the  cardiac  nerves 
superinduced  by  the  toxic  products  of  gastric  in- 
digestion. While  stress  has  been  laid  on  the  fact 
that  functional  murmurs  are  in  the  great  majority 
of  instances  systolic  in  time,  we  must  not  forget 
that  they  may  also  be  diastolic.  In  my  experience 
I  have  encountered  such  murmurs  in  anemia, 
with  their  maximum  intensity  over  the  auscultatory 
situation  of  the  aortic  orifice  and  they  may  be 
traced  to  the  jugular  veins  in  the  neck,  their  un- 
doubted point  of  origin.  Care  must  be  exercised  in 
distinguishing  such  murmurs  from  those  oc- 
curring in  aortic  incompetency,  an  error  which  is 
hardly  possible,  if  all  the  facts  in  this  chapter 
are  carefully  considered.  The  foregoing  facts 
prompt  us  to  hold  in  reserve  the  diagnosis,  "or- 


38  DISEASES   OF   THE   HEART, 

ganic  heart  murmur/'  without  repeated  examina- 
tions of  the  heart,  for  it  is  evident  that,  if  at  one 
examination,  we  note,  let  us  say,  a  systolic  murmur 
at  the  mitral  area  and  at  a  subsequent  examination 
a  systolic  tone,  as  a  rule  there  can  exist  no  organic 
disease  of  the  valve. 

ANALECTIC    EEVIEW    OF    CAEDIAC    VALVULAE    MUE- 
MUES. 

1.  The  character  or  intensity  of  a  murmur  is 
no  index  to  the  gravity  of  the  lesion  producing  it. 
The  loudest  murmur  may  be  produced  by  the 
smallest  lesion  and  vice  versa. 

2.  The  loudness  of  a  murmur  is  largely  de- 
pendent on  the  activity  of  the  heart.  Loud  mur- 
murs may  become  weak,  and  this  change  is  an 
ominous  sign  indicating  heart  weakness.  For  the 
same  reason  they  may  disappear  in  febrile  dis- 
eases and  in  the  dying  state.  Faint  may  often 
be  converted  into  loud  murmurs  after  increasing 
cardiac  activity  by  exercise  and  cardio-tonic 
medication.  Complete  compensation  may  often 
cause  the  temporary  disappearance  of  a  murmur. 

3.  In  some  individuals  murmurs  are  louder  in 
the  recumbent  than  in  the  erect  posture,  especially 
murmurs  of  tricuspid  and  mitral  origin.  Mur- 
murs should  be  auscultated  with  the  patient  in 
different  postures. 


'  DIAGNOSIS    OF   DISEASES   OF   THE  HEART.  39 

4.  Murmurs  are  less  loud  in  inspiration  than 
expiration. 

5.  Strong  pressure  on  the  chest,  especially  in 
children,  may  cause  the  disappearance  of  mur- 
murs, the  pressure  inhibiting  cardiac  action. 

6.  When  the  heart  is  rapid  or  irregular  in 
action,  it  is  difficult  to  determine  the  time  of  a 
murmur.  Eemember  that  systolic  murmurs  are 
synchronous  with  the  carotid  pulse.  Also  regu- 
late the  action  of  the  heart  with  digitalis. 

7.  Systolic  are  usually  louder  though  less  pro- 
longed than  diastolic  murmurs. 

8.  "When  murmurs  are  faint,  have  the  patient 
suspend  respiration  during  auscultation. 

9.  Murmurs  are  most  intense  at  their  point  of 
origin  and  they  are  propagated  in  the  direction  of 
the  blood  current  by  which  they  are  developed. 

10.  Murmurs  of  extra-uterine  origin  are 
oftener  found  to  proceed  from  the  valves  of  the 
left  heart,  and  in  adults,  murmurs  at  the  tri- 
cuspid and  pulmonary  areas  are  rare. 

11.  In  rare  cases  the  murmur  may  be  heard  at 
a  distance  without  laying  the  ear  over  the  chest 
and  they  may  be  perceived  by  the  patient.  Only 
those  arising  at  the  aortic  opening  have  this  pe- 
culiarity. 

12.  When  two  murmurs  co-exist  at  systole  or 
diastole  they  may  be  transmitted  or  be  due  to  dis- 
ease at  different  orifices.    Thus  two  murmurs  oc- 


40 


DISEASES   OF   THE   HEART. 


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DIAGNOSIS   OF   DISEASES   OF   THE  HEART,  41 

curring  at  systole  may  be  due  to  mitral  insuf- 
ficiency and  aortic  stenosis  or  if  occurring 
during  diastole,  to  mitral  stenosis  and  aortic 
insufiiciency.  Differentiation  is  possible  in  two 
ways :  First,  by  the  character  of  the  murmur.  If 
one  is  blowing  and  the  other  rough,  two  distinct 
murmurs  ezist.  If  both  are  similar  in  character, 
then  there  is  only  one,  which  is  transmitted  from 
its  point  of  origin  at  one  opening  to  the  second 
opening. 

Second :  Auscultate  from  the  point  where  one 
murmur  is  heard  to  where  the  other  exists,  as 
from  the  apex  to  the  aorta.  If  the  murmur  is 
everywhere  distinct  but  it  becomes  gradually 
louder  toward  one  point,  then  it  arises  at  this 
point  and  is  transmitted  to  other  points.  If,  on 
the  contrary  it  is  no  longer  heard  at  some  point 
between  the  apex  and  the  aorta,  and  is  again 
audible  at  the  aorta,  then  there  are  two  murmurs. 

13.  Never  diagnose  a  valvular  lesion  without 
taking  into  consideration  the  effects  of  such  a 
lesion  on  the  heart  and  blood  vessels  and  demon- 
strating them. 

PEEICAEDIAL  MUKMUES. 

These  are  friction  sounds  produced  by  the  rub- 
bing of  one  surface  of  the  pericardium  upon  the 
other  when  roughened  by  a  fibrinous  exudate 
which  occurs  in  the  plastic  variety  of  pericarditis. 
The  following  characteristics  will  aid  in  distin- 


43  DISEASES   OF   THE   HEART. 


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DIAGNOSIS    OF   DISEASES    OF    THE   HEART.  43 

guishing  pericardial  or  exocardial  from  endocar- 
dial murmurs: 

1.  Unlike  endocardial  murmurs  which  are 
limited  to  a  certain  phase  of  the  heart's  action, 
they  might  be  systolic,  diastolic,  or  both,  or  even 
presystolic. 

2.  They  are  increased  in  intensity  upon  pres- 
sure with  the  stethoscope,  which  maneuver  fa- 
cilitates the  friction  between  the  pericardial  layers. 

3.  During  inspiration  the  lung  approximates 
the  layers  of  the  pericardium,  thus  increasing  dur- 
ing this  phase  of  respiration,  pericardial  mur- 
murs. Endocardial  murmurs  by  the  same  act  are 
diminished  in  intensity,  because  the  interposed 
lung  offers  a  poor  medium  of  conduction  to  the 
chest  wall. 

4.  The  closer  the  two  layers  of  the  pericardi- 
um are  approximated,  the  louder  the  murmur. 
To  facilitate  this  approximation  I  would  suggest 
pressure  being  made  in  the  intercostal  spaces  and 
not  on  the  ribs,  as  is  the  conventional  practice. 
The  same  maneuver  is  applicable  in  the  elicitation 
of  pleural  friction  sounds.  To  make  pressure 
with  the  stethoscope  in  the  intercostal  space,  a 
phonendoscopic  attachment  may  be  fitted  to  the 
chest  piece  of  any  stethoscope  according  to  the 
illustration.  A  piece  of  tin  may  be  easily  fitted  by 
anv  tinsmith.  In  the  center  of  the  tin  a  rod  termi- 
nating in  a  small  button  is  screwed. 


44  DISEASES    OF   THE   HEART. 


Fig.  4 — Dr.  Abrams'  Modified  Stethoscope. 

5.  They  are  circumscribed  and  are  not  trans- 
mitted beyond  the  area  of  cardiac  dulness. 

6.  Change  of  position  exerts  a  greater  influence 
on  the  character  of  pericardial  than  endocardial 
murmurs.  The  former  are  especially  distinct 
when  the  patient  is  in  the  sitting  -posture,  with 
the  body  inclined  to  the  left  side. 

7.  They  give  the  impression  of  being  superficial 
in  origin. 

8.  They  frequently  change  their  character, 
whereas  the  character  of  endocardial  murmurs  is 
almost  constant. 

9.  They  are  rough,  grating  to  and  fro,  or  rub- 
bing and  scratching  sounds. 

10.  When  doubt  arises  whether  a  murmur  is 
peri  or  endocardial  in  origin  always  remember 
that   organic   endocardial   murmurs   modify   the 


DIAGNOSIS   OF   DISEASES   OF  THE   HEART.  45 

pulse  and  induce  secondary  eSects  upon  the  muscle 
of  the  heart. 

PLEUKO-PEEICARDIAL  MUKMURS. 

These  murmurs  often  simulate  pericardial  mur- 
murs. They  arise  when  the  pleura  or  peritoneum 
adjacent  to  the  heart  is  roughened.  They  are 
modified  by  respiratory  movement,  disappearing 
or  diminishing  when  the  breathing  is  suspended  or 
disappearing  after  forced  expiration.  Deep  in- 
spiration will  usually  accentuate  them. 

CARDIO-RESPIRATORY   MURMURS. 

These  are  sounds  synchronous  with  the  heart's 
action,  produced  outside  this  organ  and  heard  usu- 
ally to  the  left  of  the  apex  beat.  Two  factors  enter 
into  the  production  of  these  murmurs.  1.  Forcible 
expulsion  of  air  from  the  lungs  by  the  heart  strik- 
ing against  it.  2.  With  each  cardiac  contraction 
the  bulk  of  the  heart  is  reduced  in  size  and  a  cor- 
responding vacuum  produced  in  the  chest,  which 
the  lung  compensates  by  expanding,  thus  produc- 
ing a  murmur. 

a:n'emic  murmurs. 

In  anemia  murmurs  are  frequently  heard  over 
the  heart  and  vessels.  They  are  endowed  with 
certain  characteristics:  1.  Thev  are  soft  and 
blowing  in  character  and  not  prolonged.  2.  They 
are  systolic  in  time.  3.  Generally  loudest  at  the 
base  of  the  heart  and  especially  over  the  pulmonary 
orifice,  a  point  where  organic  systolic  murmurs  are 


46  DISEASES   OF  THE   HEART. 

often  heard.  The  chief  means  of  differentiation 
between  the  two  lies  in  the  fact  that  with  organic 
we  find  dilatation  and  hypertrophy  of  the  heart 
which  are  usually  absent  in  anemic  murmurs.  4. 
They  are  unaccompanied  by  changes  in  the  size 
of  the  heart.  5.  They  frequently  change  their 
character.  6.  They  are  accompanied  by  anemic 
symptoms  and  murmurs  in  the  veins  of  the  neck. 
7.  They  are  louder  in  the  recumbent  than  in  the 
upright  position.  8.  They  are  not  transmitted 
away  from  the  heart.  9.  Under  appropriate  treat- 
ment with  chalybeates  they  can  be  made  to  dis- 
appear. 

PULMONARY  ANEMIA. 

I  have  described  (Medical  Standard,  Jan.  1900) 
an  anemia  of  pulmonary  origin,  in  vfhich  anemic 
murmurs  are  frequent.  In  this  form  of  anemia 
the  ferruginous  preparations  are  without  effect 
on  the  murmurs  which  only  yield  to  systematic 
lung  development,  inasmuch  as  the  cause  of  pulmo- 
nary anemia  is  dependent  on  collapsed  areas  of 
lung. 

HEMIC  MUEMURS  IN  THE  LARGER  ARTERIES. 

The  normal  systolic  and  diastolic  heart  sounds 
are  heard  in  the  carotid  and  subclavian  arteries. 
Pressure  with  the  stethoscope  over  one  of  the  large 
arteries  will  create  a  systolic  murmur.  Murmurs 
from  the  heart  are  often  propagated  to  the  large 
arteries.     Of  all  the  arterial  murmurs  likely  to 


DIAGNOSIS   OF   DISEASES   OF   THE   HEART.  47 

perplex  the  physician,  the  subclavian  murmur  is 
the  most  frequent.  It  is  regarded  by  many  clin- 
icians as  a  sign  of  phthisis.  From  an  investiga- 
tion of  more  than  300  cases  (Vide  my  paper 
Medical  Standard,  Oct.,  1899),  I  am  able  to 
formulate  the  following  conclusions  ^ 

SUBCLAVIAN    MUKMUE. 

1.  The  subclavian  arterial  murmur  is  an  inde- 
pendent and  rarely  a  transmitted  murmur. 

2.  Its  point  of  maximum  intensity  is  the  fossa 
of  Mohrenheim,  with  feeble  tendency  to  propa- 
gation. (The  fossa  is  a  depression  under  the 
clavicle  in  the  outer  part  of  the  infraclavicular 
region  between  the  pectoralis  major  and  deltoid 
muscles. ) 

3.  It  is  heard  most  often  on  the  left  side,  less 
frequently  on  both  sides  and  least  frequently  on 
the  right  side.  In  order  of  frequency  it  is  heard  at 
the  height  of  inspiration,  at  the  end  of  expiration 
and  after  momentary  suspension  of  respiration. 

4.  It  is  usually  a  succession  of  murmurs  uni- 
form in  character  and  intensified  by  certain 
maneuvers,  notably  deep  inspiration,  suspension 
of  respiration  and  voluntary  stretching  of  the 
neck. 

5.  One  of  its  chief  characteristics  is  its  mo- 
mentary duration,  disappearing  usually  after  a 
few  deep  inspirations. 


48  DISEASES  OF  THE  HEART. 

6.  Its  dependence  on  the  phases  of  respiration 
distinguishes  it  from  all  transmitted  murmurs. 

7.  It  may  be  present  at  one  and  absent  at  a 
subsequent  examination,  and  neither  its  character 
nor  duration  is  ever  uniform  from  one  examina- 
tion to  another. 

8.  The  position  of  the  patient  may  influence  its 
genesis,  but  this  is  never  sufficiently  uniform  to  be 
of  practical  value. 

9.  A  phthisical  lung  is  not  specially  propitious 
to  its  occurrence,  as  it  is  found  nearly  as  often  in 
healthy  as  in  phthisical  persons. 

10.  It  was  present  in  thirty-six  per  cent  of  all 
healthy  persons  examined,  advantage  being  taken 
in  this  enumeration  or  re-examination  and  those 
propitious  factors  v/hich  determine  its  occurrence, 
viz. :  respiration  and  decubitus. 

11.  The  venous  subclavian  murmur  was  only 
heard  in  six  individuals  with  a  preponderance  of 
its  occurrence  on  the  right  side. 

12.  The  arterial  subclavian  murmur  could  be 
artificially  induced  on  the  left  side  in  nearly  80 
per  cent  of  all  individuals  examined,  and  on  the 
right  side  in  about  65  per  cent  of  the  cases  by  a 
simple  maneuver,  viz.,  raising  the  arm  gradually 
until  it  assumes  a  vertical  position,  while  auscul- 
tating the  Mohrenheim  fossa  during  the  time  that 
the  arm  is  brought  to  the  latter  position,  the  mur- 


DIAGNOSIS   OF   DISEASES   OF  THE   HEART.  49 

mur  suddenly  appearing  at  some  time  during  the 
execution  of  the  movement. 

13.  By  the  foregoing  maneuver  the  subclavian 
venous  murmur  could  be  induced  on  the  right 
side  in  43  per  cent  of  all  persons  examined. 

DIAGNOSIS   OF  ENLAEGEMENT   OF   THE   HEART. 

Thickening  of  the  muscular  walls  of  the  heart 
is  known  as  hypertrophy,  while  enlargement  of 
one  or  more  chambers  of  the  organ  is  known  as 
dilatation. 

HTPERTEOPHY    OF    THE    HEART. 

In  hypertrophy,  the  left  ventricle  is  most  fre- 
quently involved  owing  to  the  increased  work  put 
on  it  by  valvular  lesions,  diseases  of  the  blood 
vessels,  muscular  exertion,  etc.  Its  fellow  ventricle 
on  the  right  side  hypertrophies  in  valvular  lesions 
and  in  lung  diseases  whenever  there  is  obstruction 
to  the  blood  flow  through  the  pulmonary  organs, 
or,  as  we  often  say,  increased  resistance  in  the 
pulmonary  circulation. 

The  symptoms  of  hypertrophy  of  the  left  ven- 
tricle are  those  of  increased  tension  in  the  arterial 
system,  viz. :  congestive  headaches,  noises  in  the 
ears,  and  flushing  of  the  face.  The  physical  signs 
of  the  increased  tension  are:  forcible  and  heavy 
heart  impulse,  the  first  sound  at  the  apex  is  dull 
and  prolonged  while  the  second  aortic  tone  is 
accentuated.  The  sounds  are  of  course  modified 
if  valvular  lesions  are  present.    The  pulse  is  reg- 


So  Diseases  of  the  heart*. 

ular^  full,  strong  and  of  high  tension.  In  hyper- 
trophy of  the  right  ventricle,  increased  tension 
may  be  manifested  by  hemoptysis  owing  to  rup- 
ture of  the  blood  vessels.  Eeliance,  however,  must 
be  made  on  the  objective  examination.  Over  the 
tricuspid  area,  the  first  tone  is  louder  and  more 
prolonged  than  normal,  while  the  second  pulmonic 
tone  is  accentuated. 

Hypertrophy  is  usually  attended  by  dilatation, 
hence  in  left  ventricle  hypertrophy,  the  apex  beat 
instead  of  being  felt  in  the  fifth  interspace,  two 
inches  below  and  one  inch  to  the  right  of  the  left 
nipple,  is  felt  in  the  sixth,  seventh  or  eight  inter- 
space, from  one  to  three  inches  outside  the  nipple. 
Percussion  shows  increased  dulness  upward  and 
transversely.  If  dilatation  attends  an  hyper- 
trophied  right  ventricle  we  find,  bulging  of  the 
lower  part  of  sternum,  dislocation  of  the  apex 
beat  to  the  left^  but  rarely  displaced  downward, 
A  marked  epigastric  impulse  is  noted  in  the  angle 
between  the  ensiform  cartilage  and  the  seventh 
rib.  The  percussional  area  of  dulness  is  increased 
transversely  toward  the  right. 

DILATATION  OP  THE  IIEAET. 

Dilatation  of  the  heart  is  an  evidence  of  weak- 
ness of  the  organ  and  it  usually  follows  hyper- 
trophy. It  is  the  very  earliest  evidence  of  com- 
pensation failure.  The  symptoms  are  the  reverse 
of  hypertrophy,  because  the  ventricles  are  incap- 


DIAGNOSIS   OF  DISEASES   OF  THE   HEART.  51 

able  of  emptying  themselves  at  each  systole.  The 
apex  beat  is  of  course  dislocated  when  the  left  side 
is  involved,  but  it  is  very  feeble  and  not  punctu- 
ated, as  in  hypertrophy,  but  diffused.  When  the 
right  ventricle  is  dilated,  the  impulse  is  seen 
and  felt  to  the  right  of  the  ensiform  cartilage. 
The  action  of  the  heart  is  irregular  and  inter- 
mittent. The  heart  tones  are  feeble  and  assume 
a  fetal  heart  rhythm  (embryocardia),  i.  e.,  the  first 
and  second  heart  sounds  are  alike  and  the  long 
pause  is  shortened. 

THE   PULSE   IN   HEART   DISEASE. 

In  palpating  the  pulse  we  must  take  into  con- 
sideration :  1.  Condition  of  the  arterial  vt^all.  2. 
Tension  or  blood  pressure.  3.  Volume.  4. 
Ehythm.     5.    Frequency. 

CONDITION   OF   AETEEIAL   WALL. 

1.  In  health  the  radial  artery  can  easily  be  com- 
pressed and  distinguished  from  other  tissues.  In 
atheroma  of  the  arterial  system,  it  is  with  diffi- 
culty compressed  and  may  be  rolled  like  a  cord 
or  pipe  stem.  Atheroma  or  arterio-sclerosis  is  a 
senile  phenomenon  and  illustrates  the  fact,  that 
the  duration  of  life  is  decided  by  the  condition 
of  the  arteries  or,  axiomatically  expressed,  "A  man 
is  only  as  old  as  his  arteries."  Alcohol,  lead,  gout, 
syphilis  and  other  intoxications  are  common 
causes.  Atheroma  by  increasing  the  blood  pres- 
sure results  in  hypertrophy  of  the  left  ventricle 


53 


DISEASES   OF  THE   HEART. 


and  the  latter  sign  associated  with  a  high  tension 


Fig.  5. 
Diagram  to  illustrate  the  effect  of  dilatation  of  the 
right  and  left  sides  of  heart  respectively  (Gee  after  v. 
Dusch).  Continuous  heavy  outline,  normal  heart;  dot- 
ted line,  dilatation  of  right  side;  thin  double  line,  dila- 
tion of  left  side. 


DIAGNOSIS   OF   DISEASES   OF  THE   HEART.  53 

pulse  and  accentuation  of  the  second  aortic  sound 
are  pathognomic  of  arteriosclerosis.  Angina 
pectoris  owing  to  atheromatous  involvement  of  the 
coronary  arteries  is  common  in  arterio-sclerosis. 

TENSION"  OF  THE  PULSE. 

2.  The  pressure  with  which  the  blood  flows  in  the 
arteries  depends  upon  the  degree  of  peripheral 
resistance  and  the  force  of  the  ventricular  contrac- 
tion. ISTormally,  the  pulse  almost  subsides  between 
the  beats,  but  little  pressure  being  required  to  ob- 
literate it.  When  the  tension  is  increased,  the 
artery  remains  continuously  full  between  the  beats. 
A  pulse  of  low  tension  is  soft  and  very  compress- 
ible.   It  is  indicative  of  heart  weakness. 

VOLUME  OF  THE  PULSE. 

3.  This  is  dependent  on  the  amount  of  blood 
in  the  artery;  therefore  in  aortic  and  mitral 
stenosis  the  volume  is  small. 

PULSE  RHYTHM. 

4.  Disturbance  of  rhythm  is  manifested  by  inter- 
mission or  irregularity  of  the  pulse  beats.  Inter- 
mission means  a  dropping  of  a  pulse  beat  and  may 
occur  at  regular  or  irregular  intervals.  An  inter- 
mittent pulse  is  characteristic  of  a  fatty  heart,  if 
associated  with  a  weakened  first  heart  sound  and 
evidence  of  failing  circulation  (edema  of  the  feet). 
It  is  a  symptom  of  coffee,  tobacco,  tea  or  digitalis 
intoxication.    An  irregular  pulse  is  evidenced  by 


5i  DISEASES   OF   THE   HEART. 

differences  in  time,  force  or  volume  of  successive 
pulse  beats  and  is  of  more  serious  import  than  an 
intermittent  pulse.  It  occurs  in  mitral  lesions  and 
cardiac  degeneration. 

PEEQUENCY    OE    THE    PULSE. 

5.  In  nearly  all  valvular  heart  lesions,  except- 
ing aortic  obstruction  with  failing  compensation, 
the  pulse  may  be  increased  in  frequency.  Vagus 
disease  and  heart  weakness  are  associated  with  an 
increased  pulse  rate.  Diminished  frequency  of  the 
pulse  rate  (hradycardia)  may  be  associated  with 
certain  forms  of  cardiac  disease,  especially  aortic 
obstruction.  Appearing  late  in  valvular  lesions,  it 
is  usually  an  ominous  sign. 

The  sphygmograph  is  an  instrument  of  refine- 
ment to  the  practical  physician  in  as  much  as  pal- 
pation alone  will  detect  all  the  variations  in  the 
pulse. 

RECAPITULATION". 

Mitral  Insufficiency. — Pulse  is  small  and  feeble 
because  the  arterial  system  is  devoid  of  blood. 

Mitral  Stenosis.' — Pulse  small  and  irregular 
with  increased  frequency. 

Aortic  Insufficiency. — Eapid  recedence  of  the 
pulse  as  it  strikes  the  finger  (Corrigan's  Pulse), 
especially  if  arm  is  elevated. 

Aortic  Stenosis. — On  account  of  obstruction  to 
the  fiow  of  blood,  the  left  ventricle  is  hypertro- 


DIAGNOSIS   OF  DISEASES   OF   THE   HEART.  55 

phied,  hence  the  pulse  is  one  of  high  tension  but 
lessened  in  volume. 

Myocarditis. — Pulse  small,  soft  and  irregular; 
frequency,  normal,  diminished  or  increased. 

A  comparatively  strong  pulse,  with  feeble  apex 
beat  and  heart  tones  is  of  great  value  in  the  diag- 
nosis of  exudative  pericarditis.  The  strength  of 
the  right  ventricle  should  never  be  gauged  by  the 
pulse,  the  loudness  of  the  second  pulmonic  tone 
should  be  the  index  of  its  vigor. 

Measuking    the    Intensity    of    the    Heart 
Tones. 

"We  are  unfortunately  in  possession  of  no  accu- 
rate means  of  registering  the  heart  tones  to  facili- 
tate accuracy  in  determining  the  progress  of 
patients  with  heart  lesions,  or  the  action  of  cardio- 
tonics. I  have  already  reported  (Medical  News, 
July  8,  1899)  the  following  method,  which  is  only 
relatively  accurate: 

It  is  based  on  the  simple  physical  principle  that 
the  intensity  of  sound  varies  inversely  as  the 
square  of  the  distance  from  the  sounding  body, 
hence  the  distance  to  which  a  heart  sound  may  be 
heard  depends  upon  its  intensity,  ignoring  of 
course  those  adventitious  causes  of  propitious  con- 
ductivity. Between  the  area  auscultated  and  the 
stethoscope  a  medium  is  interposed.  Experiment 
has  taught  me  that  one  of  the  best  media  is  par- 
tially vulcanized  rubber  in  the  form  of  a  rod,  and 


56  DISEASES   OF   THE  HEART. 

just  sufficiently  soft  as  not  to  interfere  with  con- 
venient manipulation.  Such  rods  may  be  pur- 
chased in  any  store  where  rubber  goods  are  sold. 
The  circumference  of  the  rods  must  equal  the  cali- 
ber of  the  pectoral  end  of  the  stethoscope  in  which 
they  are  to  be  inserted.  The  degree  of  insertion 
must  be  regulated  by  a  notch  cut  into  the  rubber. 
The  object  of  tliis  regulation  is  to  insure  uni- 
formity of  results  in  the  examination  of  individual 
patients.  The  rods  may  be  of  different  sizes,  vary- 
ing in  length  from  6  to  26  centimeters,  or  even  of 
greater  length. 

Before  auscultating  the  heart  tones  by  this 
method,  we  must  first  mark  on  the  chest  the  dif- 
ferent points  in  the  precordial  region,  where  the 


Fig.  6. 

Rod  inserted  into  the  pectoral  extremity  of  the 
stethoscope  for  measuring  the  intensity  of  the  heart 
tones. 

heart  tones  are  heard  with  the  maximum  degree  of 
intensity.  Over  each  ostium  we  auscultate  with 
the  rod  inserted  into  the  end  of  the  stethoscope, 
beginning  with  a  rod  of  medium  length  and  grad- 
ually increasing  the  length  of  the  rod  until  one  is' 


DIAGNOSIS   OF  DISEASES   OF  THE  HEART.  57 

attained  through  which  the  heart  tones  are  no 
longer  conducted.  The  tubes  are  numbered,  and  a 
record  may  be  made  in  our  case  book  after  the  fol- 
lowing formula. 

Mitral,  I  tone 6 

Mitral,  II  tone 5 

Aortic,  I  tone 4 

Aortic,  II  tone 5 

Tricuspid,  I  tone 6 

Tricuspid,  II  tone 4 

Pulmonary,  I  tone 4 

Pulmonary,  II  tone 5 

According  to  the  foregoing  formula  we  conclude 
the  following:  That  with  a  rod  (No.  6)  which 
is  26  centimeters  in  length  we  may  still  be  able  to 
hear  the  following  tones :  Mitral  systolic  and  tri- 
cuspid systolic  tones.  A  similar  interpretation 
may  be  deduced  from  the  other  numbers.  These 
figures  possess  no  value  for  general  application  as 
the  degree  of  transmission  is  dependent  on  the 
character  of  the  stethoscope  as  well  as  the  length 
of  the  rod  employed.  Each  observer  must  cut  his 
own  rods  of  different  lengths.  With  some  kinds  of 
stethoscopes  the  first  mitral  and  tricuspid  tones 
are  still  heard  with  rods  fully  30  centimeters  in 
length,  whereas  with  other  kinds  a  rod  of  half  the 
length  will  no  longer  transmit  the  same  tones. 

In  some  instances  another  method  may  be 
adopted.  It  is  less  reliable  than  the  former 
method,  especially  in  thin  persons,  owing  to  the 


58  DISEASES   OF   THE  HEART. 

increased  conductivity  of  the  thoracic  tissues.  As 
before,  one  marks  on  the  chest  wall  the  different 
situations  where  the  heart  tones,  corresponding  to 
each  ostium,  are  heard  loudest,  and  then  proceeds 
in  different  directions  until  the  sounds  are  no 
longer  audible.  The  distance  to  which  the  sounds 
are  propagated  is  marked  and  measured.  The 
directions  in  which  the  sounds  are  auscultated 
have  been  determined  empirically  as  follows : 

Mitral  Tones. — Auscultate  along  a  line  on  a 
level  with  the  apex-beat  to  the  left  axillary  region. 

Teicuspid  Tones. — Auscultate  along  a  line  ex- 
tending from  the  point  of  auscultation  to  the  right 
axillary  region. 

Aortic  Tones. — Along  a  line  on  a  level  with 
the  point  of  auscultation  to  the  right  axillary 
region. 

Pulmonic  Tones. — From  the  point  of  auscul- 
tation to  the  left  axillary  region.  The  tricuspid 
and  mitral  tones  are  best  conducted  downward  by 
the  liver,  but  as  a  differentiation  of  the  mitral 
and  tricuspid  tones  over  the  hepatic  region  is  im- 
possible this  direction  cannot  be  employed.  I  will 
mention,  parenthetically,  that  the  liver  is  an  ex- 
cellent conductor  of  the  heart  tones,  and  when 
they  are  no  longer  audible  by  auscultation  we  can 
safely  conclude  that  the  lower  border  of  the  liver 
has  been  reached. 


DIAGNOSIS   OF   DISEASES   OF  THE   HEART.  59 

Inhibition  of  the  Heaet  as  an  Aid  in  Diag- 
nosis. 

The  inhibitory  nerve  of  the  heart  is  the  vagus, 
stimulation  of  which  stops  the  heart  in  diastole. 
Czermak  was  able  to  press  his  vagus  nerve  against 
a  little  bony  tumor  in  the  neck,  and  by  thus  sub- 
jecting the  nerve  to  mechanical  stimulation  was 
able  to  slow  or  even  stop  the  beating  of  his  own 
heart.  If,  in  almost  any  healthy  person,  the  caro- 
tid artery,  or  a  point  immediately  adjacent  to  it 
in  the  neck,  is  compressed,  slowing  or  complete 
inhibition  of  the  heart  and  pulse  ensues.  This 
phenomenon  is  explained  by  compression  of  the 
vagus  lying  alongside  the  carotid  artery. 

Friedreich,  and  subsequently  Sewell  of  Denver, 
observed  that  strong  pressure  with  the  stethoscope 
on  the  chest  could  cause  the  disappearance  of 
murmurs,  especially  in  individuals  with  an  elastic 
thorax,  which  was  attributed  to  inhibition  of  the 
heart  movements. 

I  have  endeavored  to  employ  the  phenomenon 
of  cardiac  inhibition  as  an  aid  in  diagnosis.  Ob- 
servation has  taught  me  that,  for  clinical  purposes, 
inhibition  of  the  heart  is  best  attained  by  forcible 
voluntary  contraction  of  the  muscles  of  the  neck. 
In  some  instances,  the  inhibitory  effect  on  the 
heart  is  best  observed  when  the  head  is  stretched 
backward,  and,  when  in  this  position,  contraction 
of  the  neck  muscles  is  attempted.  With  some  per- 


60  DISEASES   OF   THE  HEART. 

sons,  to  whom  no  instructions  are  intelligible,  I 
place  a  long  narrow  cushion  on  the  front  of  the 
neck  and  then  ask  them  to  press  with  all  their 
might  on  the  cushion  with  their  chin.  If  too 
much  violence  is  used  in  any  of  these  maneuvers, 
the  primary  effect  will  be  to  increase  the  rapidity 
of  the  heart. 

If  the  maneuver  is  properly  executed,  we  dimin- 
ish the  intensity  of  cardiac  tones  and  murmurs, 
and  it  is  this  fact  that  determines  the  real  value 
of  cardiac  inhibition  in  diagnosis.    A  few  seconds 

Fig.   I — Normal  pulse. 


Fig.  2 — Pulse  during  cardiac  inhibition, 
usually  elapse  before  the  effect  on  the  heart  be- 
comes manifest,  then,  while  the  subject  is  still 
forcibly  contracting  the  muscles  of  the  neck,  the 
heart  tones  become  less  and  less  evident,  assuming 
an  embryocardial  character,  until  finally  they  are 
no  longer  audible.  The  accompanying  sphygmo- 
gram  was  obtained  from  an  individual  on  whom 
the  method  was  tried  for  the  first  time. 

We  note  almost  total  annihilation  of  the  pulse 


DIAGNOSIS   OF   DISEASES   OF   THE   HEART.  61 

after  irritation  of  the  vagus  by  the  contracted 
neck  muscles.  My  investigations  with  this  maneu- 
ver may  in  brief  be  summarized  as  follows : 

1.  Organic  heart  murmurs  will  become  faint 
and  often  inaudible. 

2.  Transmitted  murmurs  are  more  amenable 
to  the  maneuver. 

3.  The  fainter  the  murmur,  the  more  easily  it 
is  suppressed. 

4.  When  a  transmitted  murmur  can  be  in- 
hibited, the  tone  which  it  masks  can  be  auscul- 
tated. 

5.  Heart  tones  are  less  amenable  than  mur- 
murs to  inhibition. 

6.  Hemic  murmurs  are  more  readily  inhibited 
than  organic  murmurs. 

7.  When  the  murmurs  of  anemia  are  inhibited, 
they  are  replaced  by  tones. 

8.  Incorrect  execution  of  the  maneuver  will 
intensify  rather  than  diminish  murmurs. 

9.  The  inhibition  maneuver  when  too  often  re- 
peated is  futile  in  its  results  owing  to  over  stimu- 
lation of  the  vagi. 

10.  The  maneuver  enables  us  to  determine  the 
condition  of  the  vagi  as  inhibitors  of  the  heart 
and  guides  us  in  the  administration  of  cardio- 
tonics. 


63  DISEASES   OF   THE   HEART. 

ILLUSTRATIVE    CASES. 

The  value  of  the  method  is  illustrated  by  the 
following  cases : 

1.  Murmur  audible  during  diastole  in  the 
second  right  interspace.  At  apex,  systolic  tone 
and  diastolic  murmur.  During  inhibition,  the 
murmur  in  the  second  right  interspace  becomes 
fainter,  while  the  diastolic  murmur  at  the  apex 
disappears  and  is  replaced  by  a  tone.  Diagnosis : 
Aortic  incompetency.  The  diastolic  murmur  at 
the  apex  is  a  transmitted  murmur. 

2.  Loud  murmur  audible  during  diastole  in 
the  second  right  interspace.  At  the  apex,  systolic 
murmur  and  diastolic  tone.  During  inhibition: 
Murmurs  over  aorta  and  apex  persist  but  are  less 
loud.  Diagnosis:  Aortic  and  mitral  incompe- 
tency. The  systolic  murmur  at  the  apex  is  not 
transmitted  but  is  dependent  on  mitral  incompe- 
tency. 

3.  Systolic  murmurs  over  all  the  ostia  an3 
not  transmitted  away  from  the  heart.  Blood 
evidence  of  anemia.  Inhibition:  Systolic  mur- 
murs replaced  by  systolic  tones.  Diagnosis :  Mur- 
murs of  anemia. 

4.  Systolic  and  diastolic  murmurs  at  base  of 
heart,  modified  by  pressure  with  stethoscope  and 
position  of  patient.  Anemia  not  present.  Inhi- 
bition :  Murmurs  disappear  and  replaced  by  tones. 
Diagnosis :    Pericardial  murmurs. 


DIAGNOSIS   OF   DISEASES   OF  THE   HEART.  63 

5.  Murmur  at  fourth  left  interspace.  Heart 
irregular,  and  rapid.  No  anemia  nor  sign  of  peri- 
carditis. Inhibition:  Murmur  disappears  to  be 
replaced  by  a  tone.  Diagnosis :  Cardio-m^uscular 
murmur. 

The  X-Ray  in  Caediac  Diagnosis. 

A  few  years  ago  I  exhibited  before  the  Califor- 
nia State  Medical  Society  a  series  of  lantern  slides 
illustrating  cardiac  lesions  diagnosed  by  the  aid  of 
the  Eoentgen  rays.  Many  of  my  auditors  no  doubt 
regarded  my  exhibit  as  manufactured  evidence, 
whereas  others,  less  captious,  were  inclined  to  re- 
gard the  demonstration  as  a  joke.  The  vast 
amount  of  literature  that  has  since  accumulated 
has  convinced  the  most  skeptical  that  the  Roentgen 
rays  are  invaluable  in  cardiac  diagnosis.  With 
the  rays,  we  can  accurately  determine  the  size  of 
the  heart  and  learn  in  what  part  the  organ  is  en- 
larged, and  all  this  with  more  certainty  than  by 
any  other  method  of  examination.  Aneurism  of 
the  heart  may  be  accurately  diagnosed,  an  impos- 
sible feat  with  other  physical  methods;  aortic 
aneurism  may  be  demonstrated  even  before  sub- 
jective symptoms  are  experienced.  By  means  of  the 
Eoentgen  rays,  we  are  enabled  to  gauge  the  action 
of  digitalis  and  the  Schott  method  of  treatment 
on  the  heart  with  perfect  ease.  Pericardial  effu- 
sion, dislocated,  transposed  and  congenital  mal- 
formations of  the  heart  may  be  accurately  de- 


64  DISEASES    OF   THE    HEART. 

termined.  For  all  this,  two  things  are  essential: 
Good  apparatus  and  the  services  of  an  expert  in- 
terpreter of  skiascopic  pictures.  Without  a  Eoent- 
gen  ray  apparatus  no  physician  can  lay  claims  to 
scientific  refinement  in  cardiac  diagnosis. 


CHAPTER  III. 

GENERAL  TREATMENT    OF  THE  DIS- 
EASES OF  THE  HEART. 

I.  Prevention.  II.  Treatment  during  compen- 
sation. III.  Treatment  during  broken 
compensation.  IV.  Treatment  of  individ- 
ual symptoms. 

Peevention. 
Acute  articular  rheumatism  is  one  of  the  chief 
predisposing  factors  in  the  etiology  of  valvular  les- 
ions. We  are  constrained  to  heed  the  wise  injunction 
of  Sibson,  that  complete  rest,  during  and  after  an 
attack  of  rheumatism  lessens  the  average  percent- 
age of  cases  in  which  cardiac  complications  de- 
velop. "We  may  profit  by  the  experience  of  Cham- 
bers, who  tells  us,  that  during  an  attack  of  rheu- 
matism, cardiac  complications  develop  less  often, 
when  patients  sleep  in  blankets  and  not  between 
sheets.  Sheets  become  wet  with  the  acid  per- 
spiration and  conduce  to  relapses  from  chilling  of 
the  skin. 

The  salicylates  are  almost  specific  for  the 
arthritis,  but  they  are  not  prophylactic  against 
cardiac  inflammation.  The  alkaline  treatment  ac- 
cording to  Garrod,  viz.:  40  grains  of  the  bicarbon- 


66  DISEASES   OF   THE   HEART. 

ate  of  potassimn  and  5  grains  of  citric  acid,  every 
2  hours  continuously  until  the  urine  becomes  and 
remains  alkaline  and  smaller  doses  thereafter,  is 
the  most  certain  means  we  possess  for  preventing 
and  arresting  heart  complications.  "With  the 
alkaline  treatment  the  use  of  salicylates  may  be 
employed. 

The  gouty  tendency  is  often  associated  with 
high  blood  tension,  arterial  degeneration  and 
cardiac  hypertrophy.  Individuals  showing  this 
tendency  must  guard  against  over-feeding,  in- 
dulgence in  alcohol  and  live  an  open  air  life  with 
an  abundance  of  well  regulated  exercise.  The  in- 
ordinate use  of  alcohol  is  an  important  factor  in 
etiology.  Arterial  degeneration  and  heart  failure 
associated  with  dilatation  of  the  organ  are  well 
recognized  conditions  in  the  inebriate. 

Tobacco,  like  alcohol,  must  be  interdicted  in 
those  who  show  a  tendency  to  cardiac  dis- 
ease. Tobacco  augments  the  cardiac  contractions 
and  induces  intermittences  and  irregularities 
(arrythmia)  of  the  heart.  In  the  etiology  of 
spurious  afigina  pectoris,  nicotine  poisoning  is 
paramount.  An  effective  argument  to  induce  to- 
bacco habitues  to  discontinue  their  habit,  is  to  in- 
struct them  to  count  the  pulse  before  and  after 
smoking,  when  they  will  invariably  note  an  in- 
crease of  from  -i  to  11  beats  a  minute.  CofEee  and 
tea  are  not  without  influence  in  the  etiology  of 


GENERAL  TREATMENT   OF   DISEASES   OF   THE   HEART.      67 

affections  of  the  heart,  notably,  functional  dis- 
turbances. 

Syphilis  is  frequently  concerned  in  endo-peri 
and  myocardial  lesions.  Arterial  syphilis  is  of 
common  occurrence.  Syphilitics,  therefore,  must 
be  vigorously  treated  by  inunctions  or  intravenous 
injections  upon  the  advent  of  cardiac  complica- 
tions. Gonorrhea  is  frequently  a  factor  in  the 
etiology  of  endocarditis,  gonococci  having  been 
frequently  demonstrated  on  the  implicated  en- 
docardium. 

Moral  hygiene  is  of  importance  in  those  predis- 
posed to  or  suffering  from  heart  disease.  All 
emotions  directly  influence  the  heart  and  the 
epigram  of  Peter  is  worth  repetition,  "The  physical 
heart  is  the  counterpart  of  a  moral  heart." 

Diet  is  of  great  moment  in  many  functional 
heart  affections.  Food  must  be  eaten  in  small 
quantities  and  be  easy  of  digestion.  Overloading 
the  stomach,  especially  at  night,  must  be  avoided. 
Carbo-hydrates,  owing  to  their  tendency  to  form 
gases,  must  be  used  sparingly.  Laxatives  mus-t  be 
given  to  aid  the  abdominal  functions.  Digestive 
reflex  neuroses  of  the  heart  are  not  infrequent  af- 
ter errors  in  diet.  Dyspnea,  palpitation  and  ir- 
regular heart,  epigastric  pulsation  and  psychic 
depression  are  a  few  of  the  symptoms  following  in- 
digestion in  some  persons. 

The  effects  of  muscular  strain  on    the    heart 


68  DISEASES   OF   THE   HEART. 

must  not  be  forgotten,  and  occupations  must  be 
recommended  which,  demand  no  excessive  nor  sud- 
den muscular  work  nor  exposure  to  cold  and  wet. 
Badly  fed  laborers  often  suffer  from  dilatation  of 
the  heart  without  valvular  disease.  In  lifting 
heavy  weights,  such  individuals,  first  take  a  deep 
inspiration  and  then  suddenly  stop  expiration  dur- 
ing the  time  severe  exertion  is  made.  The  effect 
would  be  to  empty  the  veins  into  the  chambers  of 
the  heart  leading  to  dilatation  of  the  cavities. 
Prolonged  rest  should  always  follow  heart  strain, 
otherwise  chronic  irritability  of  the  heart  with 
dilatation  ensues. 

Tkeatment  Dueing  the  Stage  of  Compensa- 
Tioisr. 

In  the  early  history  of  medicine,  patients  with 
cardiac  hypertrophy  were  made  the  subjects  of  a 
depleting  treatm.ent  and  they  were  placed  on  a 
low  diet.  Luckily  for  the  patients,  this  error  in 
therapeutics  is  no  longer  perpetrated.  The  prov- 
ince of  the  physician,  during  the  stage,  is  strictly 
limited  in  maintaining  the  vigor  of  the  heart 
muscle. 

The  great  majority  of  those  afflicted  with  com- 
pensated valvular  lesions,  suffer  no  inconvenience 
for  years  nor  is  the  duration  of  their  existence  ap- 
preciably abridged.  Clark,  in  684  chronic  val- 
vular lesions  which  had  been  kept  under  observa- 
tion for  5  years,  noted  no  physical  inconvenience 


GENERAL  TREATMENT   OF  DISEASES   OF   THE   HEART.      69 

in  any  of  the  patients.  Unfortunately,  the  belief 
yet  survives,  that  the  demonstration  of  a  cardiac 
murmur,  is  the  signal  for  digitalis,  notwithstand- 
ing compensation  is  present.  Hypertrophy  of  the 
heart,  which  is  practically  compensation,  is  an  ef- 
fort on  the  part  of  nature  to  overcome  the  cir- 
culatory disturbances  resultant  on  valvular  lesions. 

Our  efforts  must  be  directed  toward  inviting 
hypertrophy  and  when  present  to  encourage  its  ex- 
istence. We  must  "make  the  heart  equal  to  its 
task"  (Beau).  To  maintain  compensation  the  pre- 
ceding remarks  on  prevention  are  germane. 

The  rules  of  prophylaxis  can  only  be  executed 
with  the  intelligent  co-operation  of  the  patient, 
who  must  be  informed  in  a  judicious  way  of  the 
nature  of  his  trouble.  My  almost  invariable  rule 
is  to  tell  the  patient  that  his  trouble  is  purely  a 
functional  one,  that  unless  certain  laws  of  health 
are  observed,  it  may  become  organic.  The 
apothegm,  "Ignorance  is  bliss,"  is  especially  ap- 
plicable in  the  case  of  the  cardiopath.  "Hope 
springs  eternal  in  the  human  breast"  may  refer  to 
the  phthisical,  but  never  to  the  cardiac  patient. 

Systematic  exercise  must  not  be  inhibited,  on 
the  contrary,  it  is  now  regarded  as  an  invaluable 
aid  in  maintaining  the  muscular  power  of  the 
heart  and  increasing  it.  The  character  of  the  ex- 
ercise taken  is  of  little  moment,  provided  no 
dyspnea,  heart  distress  or  palpitation  follows.    The 


70  DISEASES    OF   THE    HEART. 

slightest  evidence  of  such  symptoms  is  a  signal  of 
danger. 

Provision  by  the  usual  preventive  measures 
must  be  taken  against  catching  cold.  Every  at- 
tack of  bronchitis  throws  an  additional  burden  on 
the  heart.  Climate  is  a  valuable  adjunct  in  treat- 
ment. Extremes  in  climate  must  be  avoided.  Mild 
temperate  climates  with  cool  weather  are  to  be 
favored.  High  altitudes  in  general  must  be 
avoided.  Observations  teach  us  that  it  is  the  right 
heart  which  is  first  overtaxed  by  a  sojourn  in  high 
altitudes  and  this  observation  applies  with  equal 
cogency  to  the  healthy  heart. 

Teeatment  During  Failure  of  Compensation". 

Broken  compensation  asserts  itself  slowly. 
Among  the  earliest  subjective  symptoms  are 
dyspnea  on  exertion,  nocturnal  paroxysms  of 
dyspnea  and  cardiac  distress.  Objectively,  small, 
irregular  and  feeble  pulse  and  localized  edema  are 
characteristic.  The  chief  object  of  treatment  is 
to  restore  the  enfeebled  heart  muscle  which  is  at- 
tained by  rest,  the  use  of  agents  which  stimulate 
the  heart's  action  and  by  methods  which  relieve 
the  embarrassed  circulation,  viz.:  Venesection  and 
depletion  by  purgation. 

The  heart  receives  two  sets  of  nerves,  the  ex- 
citary  from  the  sympathetic  system  and  the  mod- 
erator nerves  derived  from  the  pneumogastric. 
While  the  excitatory  nerves  put  the  heart  muscle  in 


GENERAL  TREATMENT   OF   DISEASES   OF  THE   HEART.      71 

action,  the  moderator  nerves  inhibit  the  move- 
ments, but,  by  harmonious  action  of  these  opposite 
nerve  influences,  the  regularity  of  the  heart  con- 
tractions is  due. 

Absolute  rest  in  bed  is  one  of  the  supreme  tri- 
umphs of  cardiac  therapeutics.  By  this  method 
alone,  the  relief  of  the  symptoms  of  failing  com- 
pensation is  oftentimes  phenomenal  and  but  two 
or  three  weeks'  rest  usually  suffice  to  attain  the 
object.  The  rest  must,  however,  be  as  absolute 
as  in  the  rest  cure  metl  od  of  Weir-Mitchell  and 
the  nourishment  must  be  equally  exacting.  If 
anemia  is  present,  the  liberal  use  of  some  assimil- 
able chalybeate  is  indicated.  In  addition,  we 
must  remember  +he  great  value  of  fresh  air,  sun- 
shine and  a  cheerful  environment.  Wlien  rest  in 
bed  alone  fails  to  restore  the  circulatory  equilib- 
rium, the  recourse  must  be  had  to  cardiac 
stimulants  and  tonics. 

CAEDIAC  TON"ICS. 

The  sovereign  heart  tonic  is  digitalis,  the 
quinine  of  the  heart.  Digitalis  slows  the  action  of 
the  heart  and  increases  the  force  of  its  beats;  the 
blood  pressure  in  the  arterial  system  rises  with 
contraction  of  the  peripheral  arteries.  The  physi- 
cian is  frequently  bewildered  in  encountering  in 
the  text  books,  prolix  and  elaborate  indications 
and  contraindications  for  its  use.  An  invariable 
indication  for  its  use  is  dilatation  of  the  heart. 


72  DISEASES    OF   THE    HEART, 

stationary  or  progressive,  irrespective  of  the  na- 
ture of  the  valvular  lesion.  The  phj^sician  un- 
skilled in  methods  of  cardiac  percussion  is  justified 
in  its  use,  in  all  cases  of  compensation  failure. 
There  are  some  authorities  who  declare  that  its  use 
is  dangerous  in  aortic  incompetency,  because  by 
prolonging  diastole  it  promotes  the  regurgitation 
of  blood  into  the  left  ventricle.  This  objection  is 
purely  theoretic. 

Some  contraindications  against  its  use  are  ex- 
cessive slowing  of  the  pulse  present  in  some  cases 
of  idiopathic  myocardial  disease  as  well  as  in 
stenosis  of  the  aortic  and  mitral  orifices.  The 
danger  of  arterial  rupture,  owing  to  the  increased 
blood  pressure  which  attends  its  physiologic  ac- 
tion, I  believe  to  be  theoretical.  Of  one  contra- 
indication one  can  speak  absolutely  and  that  is,  it 
should  never  be  used  when  compensation  is  prop- 
erly balanced. 

When  digitalis  acts  favorably,  we  note  the  fol- 
lowing: Pulse  becomes  slower,  regular  and  in- 
creased in  tension.  Dyspnea  and  dropsy  disappear. 
The  urine  formerly  scanty,  high  colored  and  de- 
positing urates  becomes  light  colored  with  dimin- 
ished specific  gravity  and  is  very  much  increased 
in  qu.antity.  In  the  use  of  the  drug  we  must  al- 
ways anticipate  toxic  symptoms  which  are  gradual 
in  their  appearance,  viz. :  Nausea,  vomiting,  small 
irregular  pulse  and  diminished  excretion  of  urine. 


GENERAL   TREATMENT    OF   DISEASES    OF   THE   HEART.       73 

These  symptoms  usually  disappear  when  the  drug 
is  withdrawn  and  are  rarely  serious.  Digitalis 
must  be  continued  until  compensation  has  been  re- 
stored. During  the  course  of  its  administration,  it 
is  well  to  suspend  its  use  for  a  day  or  so  in  antici- 
pation of  its  cumulative  action.  When  nausea  at- 
tends its  use,  it  may  be  given  by  the  rectum,  pre- 
ferably in  the  form  of  the  infusion. 

Digitalis  has  often  been  unjustly  discredited  as 
a  drug,  owing  to  many  inert  preparations  found 
in  the  shops.  The  most  reliable  preparations  are 
those  secured  from  trustworthy  eclectic  and 
homeopathic  pharmacists  as  they  are  in  honor 
bound  to  use  the  fresh  leaves.  After  curing, 
digitalis  leaves  rapidly  deteriorate.  Authorities 
are  not  in  accord  on  the  preparation  to  be  em- 
ployed. Some  prefer  the  watery,  others  the 
alcoholic  preparation.  The  two  preparations  are 
by  no  means  identical  in  action,  the  glucosides 
(digitalin,  digitoxin,  etc.)  vary  in  solubility  in 
alcohol  and  water.  The  watery  preparation,  the 
infusion,  is  more  effectually  diuretic  whereas  the 
tincture  has  a  more  direct  influence  on  the  heart. 
The  glucosides  ought  not  to  be  employed,  as  our 
present  knowledge  of  their  composition  and  phy- 
siologic action  is  very  uncertain. 

The  tincture  of  digitalis  is  administered  in  10  to 
15  minim  doses  every  3  or  4  hours,  the  infusion 
in  -I  ounce  doses  at  the  same  intervals.    To  secure 


74  DISEASES   OF   THE   HEART. 

the  best  results  with  digitalis,  I  am  in  the  habit 
of  giving  the  tincture  before  and  the  infusion 
after  meals.  Osier  voices  the  opinion  of  careful 
observers  when  he  expresses  the  belief  that  there 
are  no  substitutes  for  digitalis. 

Strophanthus.  This  is  the  only  cardiac  tonic 
which  possesses  any  action  similar  to  digitalis,  but 
unlike  the  latter  it  is  less  reliable  and  energetic. 
Strophanthus  increases  arterial  pressure  by  in- 
creasing the  work  of  the  heart,  but  unlike 
digitalis,  it  does  not  contract  the  blood  vessels.  It 
may  be  given  continuously  without  fear  of  toxic 
manifestations,  in  fact,  its  action  is  only  apparent 
after  long  continued  use.  In  many  instances  the 
tonic  effects  on  the  heart  initiated  by  digitalis  may 
be  continued  with  strophanthus  which  is  usually 
given  in  from  5  to  10  drop  doses  3  or  4  times  a 
day. 

Caffeine  is  regarded  by  some  as  almost  equal  to 
that  of  digitalis  in  diseases  of  the  heart.  It  causes 
the  beats  of  the  heart  to  become  stronger  and  oc- 
casionally more  rhythmical.  Unlike  digitalis  and 
strophanthus  it  has  no  specific  action  on  the  in- 
hibitory nerves  of  the  heart.  Caffeine  is  frequent- 
ly of  service  in  cardiac  disease  when  other  cardiac 
tonics  have  failed  to  give  relief  and  it  is  of  especial 
value  in  cardiac  dropsy  alone  or  combined  with 
digitalis.  Caffeine  is  given  in  doses  of  from  3  to 
5  grains,  3  or  4  times  daily  as  the  natrobenzoate 


GENERAL   TREATMENT   OF   DISEASES   OF   THE   HEART.      75 

or  natrosalicylate  owing  to  their  increased  solu- 
bility and  more  rapid  action. 

Strychnin  is  a  most  efficient  heart  stimulant  in 
sudden  heart  failure.  By  the  mouth,  in  the  doses 
usually  recommended,  I  have  seen  very  little  effect. 
It  must  be  given  hypodermically  in  doses  varying 
from  1-30  to  1-15  of  a  grain  and  frequently  re- 
peated. Lately  other  cardiac  tonics  have  been 
recommended,  but  they  are  of  subordinate  value. 
They  may  be  briefly  referred  to: 

Spartein.  Serviceable  in  valvular  disease  when 
dropsy  is  present.  Dose,  gr.  1-6  to  ^  every  4  to  6 
hours. 

Convallaria  Majalis  (lily  of  the  valley) .  Effects 
on  the  circulation  like  that  of  digitalis,  but  less 
powerful  and  decidedly  more  uncertain.  The  best 
preparation  is  the  infusion,  in  doses  of  from  3 
to  8  drachms. 

Adonis.  An  uncertain  cardiac  stimulant  with 
marked  diuretic  powers  giving  it  a  supposed  value 
in  dropsy  and  fatty  heart.  Dose  of  the  infusion,  a 
tablespoonful,  3  or  4  times  a  day. 

Nitro-glycerine.  Cardiac  stimulant  and  arterial 
relaxant.  Useful  in  aortic  valvular  lesions  when 
the  object  is  to  give  relief  to  the  violently  acting 
left  ventricle  by  dilating  the  peripheral  blood  ves- 
sels. Dose,  one  minim  three  times  a  day  of  the 
one  per  cent  solution  and  increasing  the  dose  one 


76  DISEASES    OF   THE    HEART. 

minim  each  day  until  flushing  or  headache  is  ex- 
perienced. 

Cocain.  Similar  in  action  to  strychnin.  Dose, 
^  grain  every  4  hours.  The  following  tabular  re- 
view will  recall  the  essential  facts  necessary  in 
the  administration  of  cardiac  tonics. 

THE    SCHOTT    METHODS    BY     SALINE    BATHS    A2^"D 
EESISTED    MOVEMENTS. 

These  methods  produce  phenomenal  results  in 
overcoming  the  symptoms  of  disturbed  compensa- 
tion even  after  rest,  digitalis  and  other  cardiac 
tonics  have  failed.  By  these  methods,  the  results 
achieved  are  due  practically  to,  (1,)  the  removal 
of  peripheral  resistance  which  increases  the 
arterial  circulation;  (2,)  relief  of  venous  conges- 
tion owing  to  the  increased  quantity  of  blood  in 
the  arteries;  (3,)  diminished  work  of  the  heart 
owing  to  free  circulation  of  blood  in  the  arterial 
system. 

The  Schott  treatment  is  indicated  in  all  func- 
tional disturbances  of  the  heart  and  in  valvular 
lesions  complicated  by  incompensation.  It  is  con- 
traindicated  in  aneurism,  chronic  rn3^ocarditis  and 
marked  arterio-sclerosis.  For  more  than  40  years 
the  brothers  Schott  in  Nauheim,  Germany,  have 
been  active  in  the  treatment  of  cardiac  diseases  by 
gymnastics  and  baths,  but  it  is  only  in  recent 
years  that  the  Schott  treatment  has  been  revived 


GENERAL  TREATMENT   OF   DISEASES   OF  THE  HEART. 


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78  DISEASES   OF   THE   HEART. 

in  interest.    The  methods  consist  in  baths  and  re- 
sisted movements. 

THE    BATHS. 

In  this  country,  we  are  constrained  to  use  arti- 
ficial Nauheim  baths.  While  I  do  not  underesti- 
mate the  value  of  the  natural  baths  at  Kauheim, 
I  do  not  consider  them  absolutely  essential.  Three 
of  my  patients,  who  have  taken  the  baths  at  Nau- 
heim  and  the  artificial  baths  at  home,  claim  that 
in  effects,  there  is  absolutely  no  difference  between 
the  natural  and  artificial  baths.  I  am  inclined  to 
believe  that  the  real  benefit  from  the  baths  is  de- 
pendent on  the  temperature  of  the  water  and  the 
generation  of  carbonic  acid  gas.  I  pursue  the  fol- 
lowing method,  disregarding  the  minutiae,  which 
are  of  no  practical  importance: 

In  40  gallons  of  water,  the  amount  usually 
necessary  for  body  immersion,  the  temperature  of 
which  must  be  95°  F.,  1  pound  of  sodium  bicar- 
bonate is  dissolved.  After  the  patient  is  immersed 
in  the  bath,  1-|  pounds  of  hydrochloric  acid  (25%) 
is  introduced  in  a  bottle  at  the  lower  end  of  the 
bath  tub,  which  must  of  course  be  of  porcelain  to 
avoid  the  action  of  the  acid.  Gradually  the  acid 
is  poured  from  the  bottle,  resulting  in  the  forma- 
tion of  carbonic  acid  gas.  The  patient  remains  in 
the  bath  for  15  minutes  on  an  average,  during 
which  time  he  must  remain  absolutely  quiet. 
Baths  are  given  daily  for  3  consecutive  days  and 


GENERAL  TREATMENT   OF   DISEASES   OF   THE   HEART.      79 

then  omitted  on  the  fourth  day,  or  about  21  baths 
in  one  month.  The  effects  observed  after  the  baths 
are  almost  immediate,  viz.:  lowering  of  pulse  rate 
and  increased  strength,  relief  of  cyanosis  and  dys- 
pnea, marked  reduction  in  cardiac  area  and  a  feel- 
ing of  exhilaration. 

EESISTED    MOYEilENTS. 

These  are  regular  voluntary  movements  that  the 
patient  makes  which  are  resisted  by  the  operator. 
The  movements  are  simply  flexion,  extension, 
adduction,  abduction  and  rotation  of  the  limbs, 
neck  and  trunk.  Each  single  or  combined  move- 
ment is  followed  by  an  interval  of  rest.  Patients 
must  breathe  regularly  and  uninterruptedly  during 
the  movements.  The  movements  should  be  gentle 
and  must  at  once  be  suspended  should  the  patient 
show  weariness  or  any  increase  in  the  number  of 
respirations  or  any  material  increase  in  the  num- 
ber of  pulse  beats.  The  same  muscles  should  not 
be  exercised  twice  in  succession.  The  duration  of 
each  sitting  should  at  the  beginning  not  exceed 
10  minutes,  and  after  the  patient  has  become  ac- 
customed to  the  movements,  30  minutes  is  usually 
the  time  limit. 

The  baths  give  more  permanent  effects  than  the 
movements,  whereas  a  combination  of  both  meth- 
ods yields  the  best  results.    When  both  are  used, 


80  DISEASES    OF   THE   HEART. 

the  movements  are  giyen  in  the  morning  and  the 
baths  at  night.* 

In  explanation  of  the  reduction  of  the  size  of 
the  heart  and  the  good  effects  observed  after  the 
Sehott  treatment,  I  have  espoused  the  theory  (The 
Medical  News,  Jan.  7,  1899)  that  the  baths  and 
movements  act  by  reflex  stimulation  through  the 
skin.  What  I  have  called  the  heart  reflex  (Phila- 
delphia Med.  Journal,  Jan.,  1900)  is  a  contraction 
of  the  heart  muscle  upon  application  of  a  cutane- 
ous irritant  (vigorous  rubbing  of  the  skin  or  a 
spray  of  ether  to  the  precardial  region).  This 
contraction  of  the  myocardium  is  easily  demon- 
strated, especially  in  children  by  means  of  the 
Eoentgen  rays  and  the  fluoroscope.  Vigorous 
cutaneous  friction  will  therefore  reflexly  induce 
contraction  of  the  heart  muscle. 

The  physiologic  opinion  has  been  gaining 
ground  that  the  heart  muscle  is  itself  essentially 
motor,  containing  in  its  vital  qualities  the  essential 
principles  of  its  own  activity  and  not  depending 
for  its  action  upon  its  nervous  mechanism.  Em- 
bryology furnishes  one  of  the  best  proofs  of  this 
h5^pothesis,  viz.:    that  the  heart  beats  in  the  em- 

*  The  Triton  Company  in  New  York  has  prepared 
salts  for  sale  corresponding  to  the  Nauheim  Salts. 
They  furnish  a  box  containing  sodium  bicarbonate  and 
8  cakes  of  sodium  bisulphate,  the  carbonic  acid  gas 
being  generated  by  the  action  of  these  2  salts  upon 
each  other. 


GENERAL   TREATMENT    OF    DISEASES    OF   THE    HEART.       81 

bryo  long  before  any  nerve  influence  or  fibres  can 
be  demonstrated  in  its  substance.  In  many  of  my 
patients  to  whom  the  baths  and  the  resisted  move- 
ments are  inconvenient,  I  have  employed  vigorous 
cutaneous  friction  with  rough  towels  with  most 
excellent  results.  As  a  rule,  I  initiate  the  fric- 
tions, after  the  patient  is  immersed  in  a  bath  (95° 
F.)  for  about  10  minutes. 

LUKG    GYMiSrASTICS. 

Twelve  years  ago  (Sacramento  Med.  Times, 
Sept.,  1888)  I  urgently  recommended  pneumatic 
differentiation  by  means  of  the  pneumatic  cabinet 
as  one  of  the  most  efiicient  agents  then  at  our  com- 
mand, in  overcoming  the  symptoms  of  cardiac  fail- 
ure, especially  those  dependent  on  an  embarrassed 
pulmonary  circulation.  Time  has  in  no  wise  mod- 
erated my  views.  The  disadvantages  attending  this 
method  are  the  cost  of  a  pneumatic  cabinet  and 
the  difficulty  of  its  transportation.  Eesults  nearly 
as  good  may  be  attained  by  breathing  exercises, 
systematically  and  persistently  pursued.  So  com- 
petent an  authority  as  Quimby  (Boston  Med.  and 
Surg.  Journal,  Aug.  31,  1899)  avers,  "There  is  no 
therapeutic  measure  (referring  to  valvular  lesions) 
whose  action  is  so  definite  or  constant." 

The  heart,  like  any  other  muscle,  owes  its  vigor 
to  the  activity  of  respiration.  The  exceptional 
muscular  strength  of  insects  is  no  doubt  due  to  the 
fact  that  they  respire  from  nearly  every  part  of 


82  DISEASES   OF   THE   HEART. 

their  bodies.  Individuals  with  organic  heart  dis- 
ease enjoy  the  best  health  when  they  are  able  to 
live  in  open  air  life.  The  principles  of  the  "open 
air  method"  in  the  treatment  of  phthisis  are  equal- 
ly applicable  in  organic  heart  disease.  The  excel- 
lent therapeutic  results  with  iron  in  organic  heart 
disease  depend  no  doubt  on  the  amount  of  oxygen 
conveyed  to  the  tissues.  As  a  prophylactic  against 
myocardial  degeneration,  the  value  of  an  assimi- 
lable iron  preparation  cannot  be  praised  too  high- 
ly. Owing  to  the  negative  intra-thoracic  pressure 
occurring  during  inspiration,  the  blood  is  facili- 
tated in  its  flow  to  the  chest  and  the  effect  is  en- 
hanced, the  deeper  the  respiratory  movement. 
Outside  of  the  pneumatic  cabinet,  I  know  of  no 
more  efficient  lung  exercise  than  systematic  volun- 
tary forced  inspirations  and  expirations,  the  move- 
ments of  the  thorax  being  unrestrained  by  cloth- 
ing. 

I  have  already  reported  (Medical  Fortnightly, 
Sept.,  1899)  the  results  of  my  investigations  with 
different  methods  and  different  apparatus  in  lung 
development.  This  was  done  while  the  Eoentgen 
rays  were  traversing  the  thorax,  the  index  of  lung 
inflation,  being  the  bright  reflex  as  seen  with  the 
fluorescent  screen.  The  investigations  in  brief 
demonstrated  most  emphatically  that  deep  volun- 
tary inspirations  and  expirations  secured  the  most 
thorough  lung  inflation. 


GENERAL   TREATMENT    OF    DISEASES    OF   THE   HEART.       83 

METHOD    OF    OERTEL. 

This  method  aims  in  strengthening  the  heart 
muscle  by  exercise,  diet  and  limitation  of  the  in- 
gestion of  fluids.  It  is  especially  applicable  in  the 
treatment  of  "fat  heart."  The  exercise  is  begun 
by  directing  the  patient  to  walk  on  level  ground  a 
definite  distance.  The  appearance  of  fatigue,  dys- 
pnea, or  heart  symptoms,  indicates  the  degree  of 
toleration,  when  walking  is  suspended  and  the 
patient  must  rest.  It  is  advisable  to  instruct  the 
patient  to  walk  on  some  thoroughfare  traversed  by 
a  street  car,  thus  enabling  the  patient  to  ride  home 
on  the  advent  of  fatigue.  On  the  following  day, 
the  distance  in  walking  is  to  be  increased  until 
finally  a  walk  of  a  mile  or  two  can  be  taken  each 
day  without  inconvenience.  Later,  the  patient,  un- 
der the  same  precautions,  is  instructed  to  climb 
hills,  climbing  a  certain  distance  each  day,  until, 
eventually,  the  top  of  the  hill  is  attained  without 
sense  of  fatigue.  The  diet  is  practically  that  which 
is  applied  in  the  treatment  of  obesity.  The  quan- 
tity of  fluids  taken  must  be  diminished  and  the 
tissue  fluids  must  be  eliminated  by  exercise  and 
sweat  baths. 

HOME    EXERCISE. 

When  the  ISTauheim  or  Oertel  methods  cannot 
be  conveniently  taken,  home  exercise  by  means  of 
springs  or  pulleys  in  which  resistance  can  be  ac- 
curately gauged  may  be  recommended,  always  ac- 


84  DISEASES   OF   THE   HEART. 

companying  advice  with  the  injunction,  that  exer- 
cise must  always  stop  short  of  fatigue  or  heart 
distress. 

Teeatment  op  Individttal  Symptoms. 

1.  Palpitation.  2.  Dyspnea.  3.  Dropsy.  4. 
Cough.  5.  Hemoptysis.  6.  Nervous  Symptoms. 
7.  Gastric  Complications.  8.  Renal  Complica- 
tions. 

PALPITATION. 

Relief  should  be  attempted  by  the  application  of 
an  ice-bag  over  the  heart.  At  the  same  time,  bro- 
mide of  potassium  may  be  given  in  30-grain  doses 
every  4  hours  until  relief  is  obtained.  The  latter 
drug  has  often  a  phenomenal  regulatory  influence 
on  the  heart  and  circulation,  and  its  action  is  evi- 
denced by  the  rapid  reduction  in  the  number  of 
pulse  beats.  It  also  combats  the  nervous  irrita- 
bility so  frequent  in  cardiac  patients.  Tincture  of 
aconite  (U.  S.  P.)  in  1  to  3  minim  doses  every  3 
hours,  carefully  watching  its  effects,  is  often  of 
great  value.  Under  its  influence,  the  heart-beats 
become  greatly  reduced  in  number  and  power,  the 
pulse  slow,  irregular  and  weak.  Aconite  is  of  un- 
doubted value  in  functional  cardiac  disturbances, 
but  when  the  heart  is  weak  it  must  be  used  with 
circumspection,  or  better  not  at  all.  The  further 
treatment  of  this  symptom  will  be  discussed  under 
the  treatment  of  special  diseases. 


GENERAL  TREATMENT   OF   DISEASES   OF   THE   HEART.      85 
DYSPNEA. 

Here  treatment  must  be  directed  to  the  cause: 
cardiac  dilatation,  bronchitis,  pulmonary  conges- 
tion and  hydrothorax.  The  latter  complication  is 
frequently  overlooked  in  cardiac  dyspnea.  Dyspnea 
of  a  paroxysmal  character  is  practically  nought 
else  but  cardiac  asthma,  for  which  amyl  nitrite 
inhalations  or  nitro-glycerin  internally  may  prove 
of  service.  When  everything  else  fails,  reliance 
can  always  be  placed  on  satisfactory  doses  of  mor- 
phin  given  hypodermically.  Inhalation  of  oxy- 
gen as  a  palliative  measure  may  be  tried,  but  un- 
less speedily  effective,  it  is  useless. 

DROPSY. 

Beside  the  usual  cardiac  tonics  which  augment 
the  resorption  of  fluids,  recourse  must  be  had  to 
diuretics,  purgatives  and  sudorifics.  We  must 
never  forget  that  cardiac  dropsy  always  offers  an 
increased  resistance  to  the  heart,  and  must  there- 
fore be  gotten  rid  of  as  soon  as  possible.  Cardiac 
asthma  and  lung  edema  are  often  marvelously  re- 
lieved by  agents  which  cause  a  resorption  of  the 
edematous  fluid,  digitalis  fulfills  the  double  func- 
tion of  cardiac  tonic  and  diuretic.  I  make  fre- 
quent use  of  the  following  formula: 

Infusion  of  digitalis 8  ounces. 

Diuretin    4  drams. 

A  tablespoonful  three  times  a  day  for  an  adult. 

A  combination  of  strychnin,  digitalis,  spartein. 


DISEASES   OF   THE   HEART. 


squill  and  caffein  will  often  augment  diuresis.    An- 
other excellent  combination  is  the  following: 

Acetate  of  potash 8  drams. 

Infusion  of  digitalis 8  ounces. 

A  tablespoonful  three  times  a  day  for  an  adult. 

Trousseau's  diuretic  wine  is  often  useful: 

Bruised  juniper  berries 10  drams. 

Powdered  digitalis 2  drams. 

Powdered  squill 1  dram. 

Sherry  wine 1  pint. 

Macerate  for  four  days  and  add: 

Potassium  acetate  3  drams. 

Press  and  filter. 

A  tablespoonful  three  times  a  day  for  an  adult. 

Calomel  often  proves  to  be  an  excellent  diuret- 
ic in  cardiac  dropsy,  even  when  digitalis  fails.  Dur- 
ing its  use,  the  excretion  of  uri-ne  becomes  very 
large.  When  calomel  fails  in  its  action,  we  must 
be  on  the  lookout  for  mercurialism. 

Calomel  is  given  in  2  or  3  grain  doses  combined 
with  opium  (gr.  1-6),  3  times  a  day.  The  addition 
of  the  latter  is  to  overcome  the  tendency  to 
diarrhea.  Mercurialism  is  prevented  by  mouth 
hygiene.  If  at  the  end  of  five  days  increased 
diuresis  does  not  occur,  or  if  at  any  time  during  its 
use  salivation  arises,  the  drug  must  be  suspended. 
The  diuretic  action  of  calomel  is  not  usually  man- 
ifest until  the  third  day. 

Galactotherapy. — Skimmed  milk,  2  to  3  quarts 
daily  is  followed  in  a  few  days  by  augmented  diu- 


GENERAL  TREATMENT   OF   DISEASES   OF  THE   HEART.      87 

resis.  If^  after  five  days,  the  latter  symptom  is 
not  manifest,  it  will  usually  fail.  The  ordinary 
diet  must  be  taken  in  conjunction  with  the  milk, 
as  it  is  doubtful  whether  an  exclusive  milk  diet 
can  provide  sufficient  nourishment  for  an  adult, 
a  fact  of  great  importance  where  nutrition  is  of 
such  vital  importance  in  the  restoration  broken 
compensation. 

Purgatives. — The  method  of  Hay  is  useful: 
Eochelle  or  Epsom  salts  (1  to  1^  oz.)  in  concen- 
trated solution,  taken  one  hour  before  breakfast, 
is  followed  by  3  to  6  watery  evacuations  daily. 
When  salines  fail  and  the  heart  is  strong,  drastic 
purgatives  like  the  following  may  be  used.  Pulvis 
jalapge  comp.  (3  gr.  to  1  oz.),  resina  scammonii  (5 
to  10  gr.),  extractum  colocj^nthidis  comp.  (5  to  10 
gr.),  resina  podophylli  (1  to  ^  gr.),  elaterin  (Merck), 
(1-20  to  1-12  gr.). 

Sudorifics. — Pilocarpine  is  the  ideal  diaphoretic, 
but  on  account  of  its  deleterious  action  on  the 
heart,  should  never  be  used.  Instead,  the  hot 
bath,  of  15  minutes'  duration,  after  which  the 
patient  is  wrapped  in  blankets,  may  be  used.  The 
hot  air  bath  is  often  more  convenient.  The  hot  air 
may  be  conducted  through  a  tube  under  the  bed- 
clothes raised  under  a  low  cradle.  Sweat  baths  are 
usually  well  tolerated,  although  before  using,  the 
patient  should  be  stimulated  by  whisky. 

Eelief   of  Dropsy  by  Surgical  Means. — When 


88  DISEASES   OF   THE   HEART. 

medicines  fail,  punctures  through  the  skin  to  the 
subcutaneous  tissue  of  the  lower  extremities  should 
be  made.  A  sterilized  scalpel  is  usually  employed 
for  making  the  punctures,  although  a  large-sized 
needle  is  equally  useful.  This  method  has  fallen 
into  disuse  owing  to  wound  infection  following 
the  punctures.  To  avoid  infection,  Southey  sug- 
gested using  fine  silver  trocars,  with  rubber  tubes 
attached,  so  that  the  fluid  could  run  off  gradually. 
In  this  way,  a  few  pints  of  edematous  fluid  may  be 
disposed  of  in  a  day.  After  the  incisions  are  made, 
I  frequently  employ  a  cupping  glass  to  facilitate 
the  removal  of  the  fluid.  Danger  of  infection  is 
done  away  with  entirely,  if  the  physician  conducts 
his  minor  surgery  under  the  strict  principles  of 
asepsis.  The  skin  to  be  punctured  or  incised  is 
scrubbed  and  then  washed  Avith  an  antiseptic. 
Then  with  an  aseptic  scalpel,  four  small  incisions 
are  made  on  either  side  of  the  leg  and  immediately 
covered  with  borated  cotton.  The  latter  must  be 
constantly  renewed,  when  wet,  by  sterilized  hands. 
With  the  patient  in  the  sitting  posture,  the  flow  of 
fluid  is  greater.  To  facilitate  the  rapid  removal 
of  fluid,  I  often  use  the  following  method:  Two 
incisions  are  made  on  either  side  of  the  thigh 
above  the  knee  joint;  then  a  Martin  elastic  band- 
age is  applied  beginning  at  the  foot  and  extended 
upward  to  an  inch  below  the  incisions.  The  band- 
age forces  the  fluid  toward  the  incisions. 


GENERAL   TREATMENT   OF   DISEASES   OF   THE   HEART.      89 

COUGH. 

This  is  a  common  symptom  and  frequently  re- 
sults from  stasis  in  the  pulmonary  vessels  with 
concomitant  bronchial  catarrh.  Treatment  di- 
rected toward  incompensation  is  indicated.  Codein 
may  be  tried,  although  heroin  in  tablets,  1-20  to 
1-12  gT.,  several  times  a  day  has  given  me  the  best 
results. 

HEMOPTYSIS. 

This  rarely  calls  for  treatment.  It  is  often  a 
relief  to  the  congested  pulmonary  vessels,  and  is 
rarely  fatal.  The  all-important  treatment  when 
indicated  is  absolute  rest  in  bed. 

No  faith  is  to  be  placed  on  the  conventional 
hemostatics.  The  most  reliance  to  be  placed  in 
the  hypodermic  use  of  morphin.  Gelatin  in  solu- 
tion introduced  subcutaneously,  may  be  tried.  In 
a  recent  patient  with  intractable  hemoptysis,  large 
quantities  of  flavored  gelatin  taken  by  the  mouth 
proved  efficacious.  A  similar  experience  was  had 
in  two  cases  of  purpura  hemon-hagica. 

NEEVOUS     SYMPTOMS. 

For  the  insomnia  and  peculiar  hallucinations  of 
cardiopathic  patients,  paraldehyd  and  trional  give 
excellent  results.  A  dose  of  spirits  of  chloroform 
or  ether  in  hot  whisky  will  often  give  a  quiet 
night.  Chloral  should  not  be  used.  Hydrothera- 
peutic  measures  may  be  tried,  such  as  bathing  the 


80  DISEASES   OF   THE   HEART. 

face  with  cool  water,  an  alcohol  sponge  or  a  wet 
pack  with  warm  water.  When  everything  else 
fails,  morphin,  hypodermically,  may  always  be 
depended  on. 

GASTEIC      COMPLICATIONS. 

stomach  disturbances  are  oftentimes  only  re- 
lieved when  compensation  is  restored.  Until  this 
occurs,  little  burden  should  be  thrown  on  the 
stomach  by  careful  dieting.  A  milk  diet  will  often 
bridge  over  a  period  of  gastric  irritability.  Starchy 
foods  cause  flatulency  and  must  be  proscribed. 
Concentrated  meat  extracts  may  be  tried.  They 
are  easily  absorbed,  nutritious  and  stimulating  to 
the  heart.  Of  late  I  have  used  tropon,  which 
represents  over  90  per  cent  of  pure  albumin.  It 
is  insoluble  in  water  and  may  be  given  in  soup  or 
with  the  yolk  of  an  egg.    It  is  not  palatable. 

KENAL    COMPLICATIONS. 

In  renal  complications,  diet  is  of  prime  import- 
ance. Foods  must  be  selected  which  are  capable 
of  easy  digestion,  and  which  are  least  liable  to 
produce  intestinal  poisons  and  thus  conduce  to 
auto-intoxication.  Arterial  tension  being  high  in 
these  cases,  nitrogenous  food  and  fermented  liquors 
should  not  be  used.  Pre-digested  milk  is  the  ideal 
food  relieved  by  kum^j'ss.  A  vegetable  diet,  ex- 
cluding fibrous  vegetables,  such  as  turnips,  beets, 
etc.,  and  beans  and  asparagus,  combined  with  fresh 


GENERAL  TREATMENT   OF   DISEASES   OF   THE   HEART.      91 

fruits,  is  useful.  Wlien  digitalis  is  used,  it  should 
be  employed  in  conjunction  with  nitro-glycerin. 
The  uric  acid  diathesis  must  be  remembered  as  a 
common  cause  of  high  arterial  tension,  and  the 
appropriate  treatment  must  be  directed  toward  the 
formation  of  uric  acid  and  its  excretion  from 
the  economy. 


CHAPTER  IV. 

AFFECTIONS  OF  THE  PERICARDIUM. 

Acute  Plastic  or  Fibrhstgus  Pericarditis, 
etiology. 

Earely  primary,  as  a  result  of  traumatism. 
Usually  secondary  to  the  acute  infectious  diseases. 
Acute  rheumatism  is  the  chief  etiologic  factor  in 
about  50  per  cent  of  the  cases.  Especially  in  chil- 
dren, pericarditis  may  precede  the  joint  symp- 
toms. Next  to  the  rheumatic,  tuberculous  peri- 
carditis is  the  most  frequent  variety.  The 
disease  frequently  complicates  the  septic  processes. 
It  may  be  one  of  the  earliest  symptoms  of  Bright's 
disease  especially  the  interstitial  form  (pericardite 
Brightique,  of  the  French).  Gout,  scurvy,  can- 
cer and  leukemia  are  causes.  From  the  contigu- 
ous tissues  and  organs,  inflammation  by  extension 
may  implicate  the  pericardium. 

PATHOLOGY. 

The  exudation  consists  mainly  of  fibrin.  Fluid 
may  be  present  but  never  in  large  amounts.  The 
superficial  layers  of  the  heart  muscle  may  become 
implicated  in  the  inflammatory  process  thus  en- 
tailing cardiac  asthenia  which  will  gravely  influ- 
ence the  prognosis. 


AFFECTIONS   OF   THE   PEraCARDIUM,  93 

SYMPTOMS. 

ISTo  reliance  must  be  placed  on  subjective  symp- 
toms, otherwise,  the  affection  will,  as  it  often  is, 
be  overlooked.  Pain  referred  to  the  precordia  or 
xiphoid  cartilage  may  be  present.  The  most  trust- 
worthy sign  is  the  friction  sound.  It  may  be 
palpated  but  is  more  often  heard.  1.  It  is  a  rub- 
bing, scratching  sound  and  appears  to  be  quite 
superficial.  2.  It  is  best  heard  over  the  right  ven- 
tricle, the  part  of  the  heart  approaching  nearest 
the  chest  wall,  viz.,  the  fourth  and  fifth  inter- 
spaces and  neighboring  parts  of  the  sternum.  3. 
It  is  not,  like  the  endocardial  murmur,  transmit- 
ted away  from  the  heart  4.  Its  intensity  varies 
with  the  position  of  the  patient.  5.  It  is  usually 
double,  corresponding  with  both  systole  and  dias- 
tole, but  the  synchronism  with  the  heart  tones  is 
not  absolute.  One  receives  the  impression  that  it 
is  a  superadded  sound.  I  have  frequently  found 
that  the  rubber  tip  of  the  stethoscope  will  often 
create  adventitious  sounds  not  unlike  the  friction 
murmur.  To  obviate  this  error,  my  modified 
stethoscope  illustrated  in  a  previous  chapter  will 
be  found  useful.  With  it,  one  may  make  pressure 
in  an  intercostal  space  and  thus  accentuate  the 
murmur  to  a  m^arked  degree.  The  ordinary  pho- 
nendoscope  is  not  available  for  such  a  purpose,  as 
the  least  degree  of  pressure  creates  artificial 
sounds. 


94  DISEASES    OF   THE   HEART. 


DIAGNOSIS. 


For  differentiation  from  other  friction  sounds, 
vide  chapter  on  diagnosis. 

COUESE  AND  TERMINATIOlSr. 

Usually  favorable  to  life.  Eheumatic  cases  usual- 
ly recover.  The  exudate  may  agglutinate  the  peri- 
cardial layers  {adhesive  pericarditis)  or  the  plastic 
variety  may  be  converted  into  a  pericarditis  with 
effusion. 

TREATMENT. 

Symptomatic  and  expectant.  Eoutine  measures 
are  not  justified.  One  is  reminded  of  the  story 
told  of  Sir  Wm.  Gull.  At  a  consultation,  the  lat- 
ter detected  a  pericarditis  which  had  been  over- 
looked. The  attending  physician  was  unduly 
apologetic  for  his  oversight.  Sir  William  replied, 
"Perhaps  it  is  just  as  well  you  did  not  find  it,  for 
if  you  had,  you  might  have  treated  it."  Absolute 
rest  in  bed  is  generally  demanded  to  reduce  to  a 
minimum  the  action  of  the  heart.  An  ice  bag  to 
the  precordia  relieves  pain  and  palpitation.  Hot 
applications  may  prove  more  efficient.  Blisters  to 
the  precordia,  an  old  time  practice,  is  not  justified 
by  modern  knowledge.  Their  application  interfere 
with  a  close  study  of  the  heart.  Small  doses  of 
digitalis  or  strophanthus  may  be  indicated  to  con- 
trol the  excited  heart's  action  or  when  the  pulse 
becomes  irregular,  intermittent  and  of  low  tension. 


affections  of  the  pericardium.  05 

Pericarditis  With  Effusion. 

etiology. 

A  common  sequence  of  the  previous  variety. 
About  one-third  of  the  cases  are  associated  with 
acute  rheumatism.  Phthisis,  septicemia  and 
Bright's  disease  are  among  the  etiologic  factors.  It 
may  complicate  the  eruptive  fevers  or  depend  on 
an  extension  of  inflammation  from  contiguous 
strictures. 

PATHOLOGY. 

The  effusion  is  usually  sero-fibrinous  but  may 
be  hemorrhagic  or  purulent.  The  quantity  of  fluid 
may  vary  from  six  ounces  to  four  pints.  The  peri- 
cardial layers  are  thickened  and  covered  with  fib- 
rin. In  favorable  instances,  absorption  of  the  fluid 
occurs.  As  a  rule,  the  fluid  only  is  absorbed,  the 
fibrinous'  exudate  remaining  to  form  adhesions  be- 
tween the  visceral  and  parietal  membranes.  In 
the  severe  forms  the  superficial  layer  of  the  heart 
muscle  beneath  the  visceral  pericardium  becomes 
functionally  and  anatomically  involved.  (Peri- 
myocarditis.) 

SYMPTOMS. 

No  affection  is  more  frequently  overlooked.  It 
may  develop  without  symptoms.  Pain  and  dis- 
tress in  the  precordia  may  be  the  earliest  symp- 
toms. Pressure  symptoms  depend  on  the  amount 
of  the  effusion. 


DISEASES   OF   THE   HEART. 


Dyspnea  or  orthopnea  is  an  early  symptom  of 
pressure. 

Aphonia,  due  to  compression  of  the  recurrent 
laryngeal  as  it  winds  round  the  aorta,  dysphagia, 
from  pressure  on  the  esophagus,  irritative  cough, 
from  compression  of  the  trachea,  distension  of  the 
veins  of  the  neck  and  compression  of  the  left  lung 
are  other  pressure  signs.  Altered  cardiac  rhythm 
due  to  the  mechanic  effects  of  the  fluid  on  the  heart 
interfering  with  its  action  is  common.  The  pulse 
is  rapid,  intermittent  and  small.  The  paradoxical 
pulse  may  be  present,  i.  e.,  a  pulse  in  which  the 
beats  become  weak  or  lost  with  each  inspiration. 

Wlien  the  effusion  is  not  large,  a  very  important 
rational  sign  to  remember  is,  that  the  apex  heat 
which  is  with  diificuUy  palpated,  may  he  associated 
with  a  comparatively  strong  pulse. 

The  onset  of  the  disease  may  be  characterized  by 
cerebral  symptoms.  The  patient  is  delirious  or 
may  become  melancholic  and  show  suicidal  tenden- 
cies. The  condition  may  resemble  delirium  tre- 
mens. The  occurrence  of  delirium  in  acute  rheu- 
matic fever  should  at  once  direct  attention  to  the 
heart. 

PHYSICAL  SIGNS. 

Inspection  and  Palpation.  In  young  subjects, 
there  is  precordial  prominence  with  obliteration 
and  even  bulging  of  the  intercostal  spaces.  The 
apical  beat  is  diffused  or  lost  and  if  felt,  is  raised 


AFFECTIONS    OF   THE    PERICARDIUM.  97 

and  dislocated  outward.  Adhesions  of  pericardial 
origin  may  retain  the  apex  to  the  chest  wall  de- 
spite the  effusion.  Ewart's  sign,  in  which  it  is 
possible  to  feel  the  upper  edge  of  the  first  rib  to- 
gether with  its  inspiratory  and  expiratory  move- 
ments is  regarded  as  trustworthy  although  it  also 
occurs  in  some  cases  of  heart  dilatation. 

Percussion.  This  is  to  be  relied  on  most  in  diag- 
nosis. The  precordial  figure  of  dullness  is  ir- 
regularly pear  shaped;  the  base  directed  down- 
ward and  the  stem  or  apex  directed  toward  the 
upper  end  of  the  sternum. 

Sternal  dullness  is  a  suggestive  sign.  ISTormally 
the  sternum  is  resonant  owing  to  the  contact  of  its 
upper  part  with  the  lungs.  When  this  contact 
ceases  to  exist,  as  occurs  in  pericardial  effusion 
when  the  lungs  are  separated  from  the  sternum, 
percussion  of  the  latter  bone  will  yield  dullness. 
This  sign  cannot  be  regarded  as  diagnostic  because 
an  enlarged  heart  may  have  the  same  effect  on  the 
lungs. 

The  Eotch  sign  is  important  in  diagnosis.  As 
a  result  of  effusion  within  the  right  corner  of  the 
pericardial  sac,  the  usually  resonant  area  in  ques- 
tion may  become  dull  on  percussion.  This  area  is 
in  the  right  fifth  intercartilaginous  space  formed 
by  the  right  border  of  the  heart  and  right  lobe  of 
the  liver  (cardio-hepatic  triangle).  Dullness  of 
the  triangle  has  been  observed,  though  rarely,  in 


93  DISEASES    OF   THE   HEART. 

cases  of  enorinoiis  dilatation  of  the  right  auricle 
from  tricuspid  stenosis. 

Depression  of  the  liver  is  more  marked  in  peri- 
cardial effusions  than  in  any  other  intra-thoracic 
affection,  the  possible  exception  being  pneumo- 
thorax. The  hepatic  percussion  note  may  begin  at 
the  level  of  the  tip  of  the  xiphoid  instead  of  at 
the  infra-sternal  notch.  As  a  result  of  the  depres- 
sion, the  fingers  applied  below  or  at  the  side  of  the 
xiphoid  can  be  made,  by  pushing  upwards  and 
backwards,  to  ride  over  the  upper  surface  of  the 
liver,  v/hich  is  normally  out  of  reach. 

The  posterior  pericardial  patch  of  dullness  in 
association  with  other  symptoms  furnishes  a  com- 
plete and  crucial  evidence  of  fluid.  Whenever  fluid 
accumulates  in  the  pericardium,  a  marked  patch 
of  dullness  is  found  at  the  left  inner  base,  extend- 
ing from  the  spine  for  varying  distances  outward. 

The  Eespiratory  Sign.  I  have  designated  this 
the  respiratory  sign  because  the  area  of  precordial 
dullness  is  dependent  on  the  amount  of  air  in  the 
lungs.  ISTormally  it  is  possible  to  obliterate  the 
superficial  area  of  cardiac  dullness  by  deep  in- 
spiration. Even  in  extreme  cases  of  cardiac  dila- 
tation, the  area  of  heart  dullness  may  be  dimin- 
ished by  forced  inspiration.  In  effusions,  the  in- 
fluence of  forced  inspiration  is  extremely  slight 
or  absent. 

Auscultation.    The  heart  tones  are  feeble  or  dis- 


AFFECTIONS    OF   THE   PEPaCARDIUM. 


99 


tant  and  scarcely  heard.  The  friction  sound  heard 
in  the  beginning  may  disappear  but  often  persists 
at  the  base  or  perhaps  at  a  limited  area  of  the 
apex.  An  important  sign,  if  the  patient  is  seen 
early,  is  to  note  the  diminishing  loudness  of  the 
heart  tones  with  increasing  effusion. 


Fig.  9— Illustrating  "Rotch's  sign"  (dullness  in  the 
right  5th  space — 5  to  H);  also  contrasting  the  angle 
(on  either  side  of  H)  of  the  dullness  as  due  respectively 
to  effusion  and  to  dilatation.  The  heart's  outline  is  nor- 
mal in  size  and  position.  The  outer  lines  are  those 
of  the  dullness  in  moderate  efifusions.  The  "supra- 
hepatic  line"  (dotted)  and  the  "hepatic  line"  limit  the 
normal  "modified"  dullness  of  the  liver;  and  H  is 
placed  on  the  absolute  dullness. — (Ewart.) 

Bamberger's  Sign.  When  the  patient  is  sitting 
upright  an  area  of  dullness  about  the  size  of  a 
silver  dollar  can  be  detected  at  the  angle  of  the 
scapula.  On  auscultation  of  this  area,  tubular 
breathing  is  heard.    If  the  patient  leans  forward. 


100 


DISEASES    OF   THE    HEART. 


dullness  and  tubular  breathing  disappear  but  re- 
appear wiien  the  erect  posture  is  again  maintained. 
A  valuable  sign. 

The  Eoentgen  rays.  Guided  by  my  individual 
experience,  I  know  of  no  means  simpler  and  at- 
tended with  less  danger  of  error  than  the  X-rays. 
By  their  aid,  one  is  able  to  map  out  the  contour 


Fig.  10 — The  posterior  pericardial  patch  of  dullness 
sign  (shaded)  and  Bamberger's  sign  (T  A).  The  pos- 
terior pericardial  patch  of  dullness  is  shaded.  T  A — 
Posterior  patch  of  tubular  breathing  and  egophony. 

of  the  heart  in  its  entirety.  One  can  always  de- 
tect in  the  normal  heart  some  movement  especially 
in  the  left  ventricle.  Such  movements  are  not 
discernible  in  effusions  but  it  may  happen  that  an 
evanescent  wave  transmitted  to  the  fluid  by  the 
heart  may  lead  to  an  error  in  diagnosis.    If,  how- 


AFFECTIONS   OF   THE   PERICARDIUM.  101 

ever,  one  provokes  the  heart  reflex,  the  danger  of 
misinterpretation  is  reduced  to  a  minimum.  The 
reflex  is  a  phenomenon  observed  by  means  of  the 
X-rays.  It  is  a  momentary  contraction  of  the 
heart  muscle  upon  application  of  an  irritant  to  the 
skin  of  the  precordia.  Stroking  the  skin  with  a 
lead  pencil  or  the  finger  nail  suffices  to  call  forth 
the  reflex.  The  elicitation  of  the  reflex  is  impossi- 
ble in  effusion. 

DIAGNOSIS. 

There  are  three  characteristic  signs  of  a  peri- 
cardial effusion.  1.  The  apex  beat  located  by  pal- 
pation or  auscultation  is  found  an  inch  or  two 
within  the  left  border  of  precordial  dullness.  2. 
The  cardiac  impulse  is  feeble  and  appreciated  with 
difficulty.  3.  The  feeble  and  distant  heart  tones 
are  in  marked  contrast  with  a  comparatively  strong 
radial  pulse.  4.  The  shape  of  the  figure  of  pre- 
cordial dullness. 

Dilatation  of  the  heart  offers  the  greatest  draw- 
back in  differential  diagnosis.  The  following  facts 
are  in  favor  of  heart  dilatation. 

1.     Previous  history  of  valvular  heart  disease. 

2.  Absence  of  fever,  pain  and  pressure  symptoms. 

3.  The  heart  impulse  is  usually  visible  and  wavy 
and  the  apex  beat  is  visible  and  diffused.  The 
shock  of  the  cardiac  tones  may  be  felt  4.  The  area 
of  dullness  rarely  assumes  the  triangular  form,  nor 
does  it  excepting  in  metral  stenosis  reach  so  high 


103  DISEASES   OF   THE   HEART. 

or  so  low  without  visible  or  palpable  impulse.  5. 
The  tympanitic  tone  in  the  axillary  region  owing 
to  lung  compression  often  present  in  effusion  is 
absent  in  heart  dilatation.  6.  The  heart  sounds 
are  clear  and  sharp  and  there  is  no  friction 
murmur. 

CIIAEACTEE  OF  THE  FLUID  EXUDATE. 

In  rheumatism,  the  exudate  is  usually  sero-fib- 
rinous,  purulent  in  septic  and  tuberculous  cases; 
hemorrhagic  in  nephritic,  tuberculous  and  senile 
individuals.  The  only  positive  means  of  deter- 
mining the  nature  of  the  fluid  is  by  aspiration 
(paracentesis  pericardii).  This  may  be  done  with 
an  hypodermic  needle  under  aseptic  conditions. 
The  following  points  of  election  may  be  chosen, 
preference  being  given  to  the  first :  1.  Fifth  left 
intercostal  space,  an  inch  and  a  half  from  the 
edge  of  the  sternum.  2.  Lower  left  part  of  the 
pericardial  sac  just  within  the  margin  of  dullness, 
3.  Left  costo-xiphoid  angle.  When  the  needle  has 
entered  the  pericardial  sac,  suction  is  used.  Punc- 
ture of  the  heart  has  repeatedly  occurred  without 
any  special  danger  and  only  one  fatal  case  has  been 
reported.  To  avoid  damage  to  the  heart,  the  use 
of  a  trocar  and  eanula  has  been  suggested.  A  sin- 
gle aspiration  with  negative  results  is  not  sufficient 
to  exclude  fluid  when  the  physical  signs  are  strong- 
ly suggestive  of  its  pressure. 


AFFECTIONS   OF   THE   PERICARDIUM,  103 

COURSE  AND  TEEMINATION. 

The  course  of  an  effusion  may  be  controlled  by 
demarcating  the  figure  of  dullness  hj  means  of  a 
nitrate  of  silver  pencil.  Sero-fibrinous  effusions 
may  reach  a  maximum  in  forty-eight  hours  and 
are  often  absorbed  with  equal  rapidit}^  When  the 
effusion  lasts  weeks,  it  is  referred  to  as  chronic. 
Sero-fibrinous  effusions  usually  undergo  absorption 
although  pericardial  adhesions  remain.  Cases  that 
tend  to  a  fatal  end  are  m.arked  by  pressure  symp- 
toms; increasing  dyspnea,  cyanosis  and  failing 
circulation.  Nervous  symptoms  are  of  grave  im- 
port and  unless  they  remit,  death  may  occur  within 
ten  days.  When  a  large  effusion  persists  for  weeks, 
death  may  result  from  cardiac  asthenia.  Etiology 
influences  the  prognosis,  rheumatic  pericarditis 
tends  to  recovery,  whereas  the  tuberculous  form  is 
as  a  rule  fatal. 

TREATMENT. 

The  essential  object  is  to  aid  absorption  of  the 
fluid.  A  variety  of  methods  have  been  suggested : 
Blisters  to  the  precordia  are  warmly  recommended 
by  Osier.  Purges  and  diuretics  may  be  tried. 
Iodide  of  potash  and  digitalis  are  employed.  De- 
pressing measures  are  always  contra-indicated. 
Diaphoretic  methods  are  used.  Sodium  salicylate 
has  often  a  very  favorable  action  in  hastening  ab- 
sorption. Piloearpin  has  been  recommended  but 
its  use  must  be  preceded  by  large  dose  of  some 


104  DISEASES   OF  THE   HEART. 

alcoholic  to  prevent  collapse  symptoms.  When 
these  methods  fail  or  when  death  is  imminent  from 
cardiac  pressure,  indicated  by  increasing  dyspnea, 
cyanosis  and  small  rapid  pulse,  procrastination  is 
fatal  and  recourse  must  be  had  to  tapping.  Punc- 
ture is  usually  made  in  the  fifth  interspace  an  inch 
and  a  half  from  the  left  sternal  margin  with  the 
strictest  asepsis  and  the  amount  of  liquid  with- 
drawn should  not  exceed  2-3  ounces  at  any  one 
time.  It  is  wiser  to  repeat  the  puncture  several 
times  rather  than  to  remove  the  pressure  too  sud- 
denly from  the  heart.  If  possible,  the  patient 
should  be  tapped  in  the  recumbent  position,  for  in 
this  decubitus,  the  heart  being  heavier  than  the 
fluid  sinks  toward  the  back  and  is  out  of  reach  of 
the  needle.  In  addition  to  aspiration,  some  writers 
recommend  the  subsequent  injection  of  iodin  dis- 
solved with  potassium  iodide  in  water.  Aspira- 
tion is  generally  successful  if  not  too  long  delayed. 

PURULENT    PEPJCARDITIS. 

This  form  is  characterized  at  the  onset  by  fre- 
quently recuiring  rigors,  intermittent  type  of 
fever,  early  prostration  and  a  rapid  and  unfavor- 
able course.  The  etiology  and  symptomatology 
suggest  the  character  of  the  fluid  and  aspiration 
proves  it. 

The  treatment  is  essentially  surgical.  Paracen- 
tesis is  not  sufficient  to  cure  it.  Incision  and 
drainage  are  essential  and  should  not  be  delayed. 


AFFECTIONS   OF   THE    PERICARDIUM.  105 

The  prognosis  is  comparatively  good  after  pericar- 
diotomy for  pyopericardium.  Eoberts  collected  26 
cases,  showing  10  recoveries  and  16  deaths.  Of  the 
fatal  cases,  9  were  septic,  and  all  the  others  which 
died  had  severe  complications. 

Chronic    Adhesive    Pericabditis. — Adherent 
Pericardium. 

etiology  and  pathology. 
Eesults  from  the  acute  form.  The  adhesions 
(synechia)  may  be  partial  or  general  leading  to 
complete  obliteration  of  the  pericardial  sac.  The 
outer  surface  of  the  pericardium  may  become  ad- 
herent to  the  pleura,  chest  wall  or  mediastinal  tis- 
sues. The  heart  muscle  shows  atrophic  and  degen- 
erative changes. 

symptoms. 

Inspection  and  Palpation.  Eetraction  of  the 
interspaces  and  even  the  ribs  at  the  time  of  systole 
of  the  ventricles.  Dislocation  of  the  apes  outward 
and  increase  of  the  area  of  impulse  caused  by  the 
cardiac  hypertrophy  wliich  frequently  complicates 
the  synechia.  A  quick  rebound,  known  as  the 
diastolic  shock  occurring  after  systole  is  regarded 
as  characteristic.  Collapse  of  the  cervical  veins 
(sign  of  Friedreich)  occurs  during  diastole  of  the 
heart.  Inspiratory  swelling  of  the  veins  of  the 
neck  (sign  of  Kussmaul)  may  be  observed.  The 
pulsus  paradoxus  is  sometimes  present.     It  is  a 


106  DISEASES   OF  THE  HEART. 

pulse  small  and  feeble  during  inspiration  and  gains 
strength  and  volume  during  expiration. 

Percussion  sho^rs  increase  in  cardiac  dullness 
especially  upward  and  to  the  left.  When  pleural 
adhesions  complicate  the  trouble,  the  area  of  car- 
diac dullness  is  not  diminished  when  the  patient 
takes  a  deep  breath. 

Auscultation  may  reveal  the  signs  of  dilatation 
or  hypertrophy. 

TREATMENT. 

This  concerns  itself  with  the  nutrition  of  the 
heart  muscle  on  the  lines  indicated  in  the  treat- 
ment of  valvular  lesions.  The  embarrassed  heart 
may  stop  suddenly  in  fatal  syncope  or  pass  through 
the  stages  of  broken  compensation. 

Mediastino-Peeicaeditis. 

etiology  and  pathology. 
Occurs  most  frequently  in  young  adults  and 
males  from  an  extension  of  the  pericardial  inflam- 
mation to  the  anterior  mediastinum.  The  pericar- 
dium is  thickened  and  adherent  to  the  structures 
in  the  anterior  mediastinum. 

SYMPTOMS. 

Dyspnea,  cyanosis,  venous  engorgement,  liver 
enlargement,  ascites  and  anasarca.  The  physical 
signs  are  those  of  adherent  pericardium.  The 
mediastinal  friction,  systolic  in  time,  heard  over 


AFFECTIONS    OF   THE   PERICARDIUM.  107 

the  sternum  and  increased  in  intensity  when  the 
arm  is  raised  has  been  observed  by  Perez. 

Hydeopeeicaedium. — Dropsy   of   the  Peeicae- 

DIUM. 
ETIOLOGY   AND  PATHOLOGY. 

The  occurrence  of  fluid  in  the  pericardium  with- 
out inflammation  of  the  serous  sac.  The  serous 
transudate  is  secondary  and  associated  with  cardiac 
or  renal  dropsy  when  other  serous  cavities  are  sim- 
ilarly occupied  by  fluid.  Fluid  may  accumulate 
suddenly  in  nephritis  especially  in  the  scarlatinal 
form.  Intra-thoracic  mechanical  causes  may  con- 
tribute to  the  accumulation  of  a  non-inflammatory 
fluid  in  the  pericardium.  When  the  serum  has  a 
milky  character  it  is  known  as  chylo-pericardium. 

The  symptoms  are  those  of  effusion  without 
fever  or  friction  murmurs.  The  treatment  is  that 
indicated  in  general  dropsy  although  aspiration 
may  be  necessary. 

HEMOPEEICAEDIUM. 

The  causes  are:  Eupture  of  the  first  part  of 
the  aorta,  the  coronary  arteries  or  the  heart. 
Wounds  of  the  heart  and  pericardium  are  further 
causes.  Death  may  occur  before  symptoms  de- 
velop especially  in  ruptured  aneurisms.  In  tu- 
berculosis and  cancer,  the  effusion  may  be  blood- 
stained and  must  not  be  regarded  as  instances  of 
hemoperic&rdium,    Death  results  from  heart  fail- 


108  DISEASES   OF   THE   HEART. 

ure,  the  result  of  compression.  Aspiration  has 
been  successful  in  a  limited  number  of  traumatic 
cases. 

PNEUMOPERICAEDIUM . 

Air  or  gas  in  the  pericardial  sac  is  rare  and  is 
caused  generally  by  perforated  thoracic  wounds 
or  the  result  of  perforation  from  the  lungs,  sto- 
mach or  esophagus.  Decomposition  of  pus  in  the 
sac  may  develop  gases.  When  pus  is  present,  we 
speak  of  a  pyo-pneumopericardium.  The  physical 
signs  are  those  yielded  by  the  pressure  of  fluid  and 
gas.  Percussion  gives  a  movable  arc  of  dullness 
by  altering  the  patient's  posture  with  a  tympanitic 
sound  in  the  region  of  the  gas.  The  heart  sounds 
on  auscultation  assume  a  metallic  splashing  char- 
acter. Death  rapidly  occurs  unless  the  trouble  is 
caused  by  perforation  from  without. 

Treatment  is  indicated  in  the  latter  instance  by 
enlargement  of  the  wound  and  free  incision.  Air 
is  sometimes  spontaneously  absorbed  as  in  pneu- 
mothorax. 


CHAPTER  V. 

ENDOCARDITIS  AND  CHRONIC 
VALVULAR  DISEASE. 

E]I^DOCAEDITIS. 
ETIOLOGY  AND   PATHOLOGY. 

Inflammation  of  the  lining  membrane  of  the 
heart  is  usually  confined  to  the  valves  and  is  gen- 
erally a  secondary  infection  in  the  course  of  vari- 
ous diseases.  The  pathologic  antecedent  is  gen- 
erally acute  articular  rheumatism,  the  etiologic 
elements  of  which  have  not  yet  been  established. 
The  arthritic  phenomena  may  be  secondary  to  the 
endocardial  inflammation.  When  secondary  to 
erysipelas,  the  streptococcus  pyogenes  may  be  dem- 
onstrated. In  the  suppurative  processes,  like  py- 
emia and  puerperal  fever  strepto  and  staphylococci 
are  found.  Endocarditis  following  croupous  pneu- 
monia and  pulmonary  tuberculosis  is  not  uncom- 
mon. Osier  in  100  autopsies  in  pneumonia  cases 
found  it  present  in  5  instances  and  in  216  necrop- 
sies on  phthisical  cases,  it  was  present  in  12  in- 
stances. Diphtheric  endocarditis  is  not  frequent 
and  the  same  statement  applies  to  typhoid  endocar- 
ditis which  is  caused  by  the  typhoid  bacillus. 

In  gonorrheal  endocarditis  which  is  not  infre- 
quent, the  gonococcus  has  been  frequently  demon- 


110  DISEASES   OF   THE   HEART. 

strated  in  the  endocarditic  vegetations.  In  the 
endocardial  inflammation  complicating  acute 
nephritis,  the  micro-organisms  concerned  in  pro- 
ducing the  nephritis  are  the  exciting  agents. 

Pathologically  the  different  forms  of  endocardi- 
tis are  characterized  as  follows :  Simple  acute 
endocarditis  shows  the  presence  of  minute  vege- 
tations on  the  valves  of  a  warty  appearance.  These 
vegetations  may  be  absorbed,  result  in  the  produc- 
tion of  an  ulcer  or  end  in  chronic  valvulitis  with 
deformity. 

Malignant  or  ulcerative  endocarditis  is  charac- 
terized by  rapidly  occurring  ulceration  of  the 
valves,  heart  septum  or  the  heart  itself.  Suppu- 
ration may  complicate  the  ulceration. 

Chronic  Endocarditis  is  an  interstitial  inflam- 
mation of  the  heart  valves  leading  to  deformity 
of  the  valve  segments.  It  is  a  slow  process  and  is 
the  usual  cause  of  chronic  valvular  disease.  Syph- 
ilis, gout,  alcoholism  and  prolonged  muscular  ex- 
ertion are  the  usual  causes. 

DIAGNOSIS, 

Simple  Endocarditis.  The  subjective  symp- 
toms are  usually  negative.  The  physical  signs  are 
alone  conclusive.  In  the  course  of  an  infectious 
disease,  cardiac  complication  is  betrayed  by  pal- 
pitation and  irregularity  of  the  heart. 

The  physical  signs  are  evident  by  auscultation. 
Murmurs  or  roughened  heart  sounds  may  be  pres- 


ENDOCARDITIS   AND   CHRONIC   VALVULAR  DISEASE.       Ill 

ent.  Very  frequently  the  physical  signs  are  dubi- 
ous. The  occurrence  of  fever  of  moderate  range 
(100-102  deg.  F.)  together  with  a  murmur  over 
one  of  the  heart  orifices  with  perhaps  irregularity 
in  the  organ  speak  for  endocarditis.  One  must  not 
mistake  the  soft  bellows  murmur  often  heard  in 
acute  febrile  diseases  usually  heard  over  the  aortic 
area  with  the  murmurs  occurring  in  endocarditis 
which  are  best  heard  over  the  mitral  area. 

Malignant  endocarditis  presents  two  distinct 
types,  the  septic  or  pyemic  and  the  typhoid.  The 
septic  type  associated  with  wounds  and  septic  pro- 
cesses is  characterized  by  chills,  sweats,  irregular 
fever  and  the  usual  phenomena  of  septic  infection. 
This  type  has  been  known  to  be  frequently  mis- 
taken for  intermittent  fever. 

The  typhoid  type  is  more  frequent  than  the 
former  and  is  manifested  by  irregular  tempera- 
ture, delirium,  prostration,  coma,  diarrhea  and 
sweating.  Petechial  rashes  and  er}i;hema  are  com- 
mon in  both  types  as  well  as  embolic  phenomena. 
The  emboli  take  their  origin  from  the  soft  vege- 
tations on  the  valves  and  are  carried  to  the  differ- 
ent organs.  When  the  emboli  go  to  the  brain,  de- 
lirium, coma,  aphasia  or  hemiplegia  results;  to 
the  kidney,  hematuria;  to  the  spleen,  local  peri- 
tonitis; to  the  skin,  minute  hemorrhages. 

The  physical  signs  are  notoriously  uncertain.  A 
murmur  may  or  may  not  be  present.    A  murmur 


Il3  DISEASES  OF  THE  HEART. 

varying  in  character  from  day  to  day  is  charac- 
teristic of  malignant  endocarditis.  Malignant  en- 
docarditis may  develop  in  consequence  of  infection 
on  an  old  valvular  heart  lesion.  The  diagnosis  is 
easy  when  embolic  phenomena  occur  associated 
with  irregular  fever,  profound  prostration  and  the 
presence  of  heart  symptoms. 

DIFFERENTIAL    DIAGNOSIS. 

From  malaria,  endocarditis  of  a  malignant  type 
may  be  excluded  by  an  examination  of  the  blood. 
From  cerebro-spinal  fever,  we  must  rely  on  the 
preponderance  of  cardiac  symptoms.  From  ty- 
phoid fever,  with  which  disease  it  is  most  frequent- 
ly confounded,  the  following  symptoms  speak 
against  typhoid  fever  and  for  malignant  endocar- 
ditis; history  of  rheumatism,  pneumonia  or  some 
infectious  disease,  no  prodromata,  onset  marked 
by  a  severe  chill,  rapid  rise  of  temperature  of  an 
irregular  t3rpe,  profound  prostration  early,  embolic 
symptoms  (hemiplegia,  aphasia,  hematuria,  etc.), 
cardiac  symptoms  (loud  systolic  murmur),  septic 
leucocytosis. 

Chronic  Endocarditis  manifests  itself  by  the 
presence  of  symptoms  peculiar  to  chronic  valvular 
disease  which  will  be  considered  under  special 
lesions  of  the  valves. 

COURSE  AND  TERMINATION. 

In  simple  acute  endocarditis,  there  is  rarely  any 
immediate  danger,  the  prognosis  depending  on  the 


ENDOCARDITIS   AND   CHRONIC   VALVULAR   DISEASE.       113 

character  of  the  primary  disease.  As  a  rule,  this 
form  of  endocarditis  is  the  initial  factor  in  the 
development  of  permanent  valvular  lesions  of  the 
heart.  In  malignant  endocarditis  the  prognosis 
is  likewise  dependent  on  the  primary  disease.  Un- 
less grafted  upon  a  chronic  valve  lesion,  the  dis- 
ease rapidly  tends  toward  a  fatal  termination,  the 
course  rarely  lasting  more  than  six  weeks,  where- 
as in  some  instances,  the  disease  may  terminate 
fatally  in  a  few  days.  In  one  of  my  patients  with 
gonorrheal  endocarditis,  the  disease  lasted  only 
three  days.  It  was  marked  by  emboli  which  com- 
pletely cut  off  the  circulation  in  three  of  the  fin- 
gers of  one  hand.  In  the  chronic  form,  the  prog- 
nosis is  that  of  the  individual  lesions  of  the  valves. 

TREATMENT. 

No  measures  are  yet  known  by  which  endocardi- 
tis can  be  prevented  although  absolute  rest  in  bed 
and  protection  of  the  body  against  cold  in  the 
specific  fevers,  may  diminish  the  tendency  to  the 
disease.  The  value  of  the  salicylates  in  rheuma- 
tism while  undoubted  have  little  influence  in  pre- 
venting endocarditis.  We  have  no  remedy  which 
will  directly  influence  the  endocarditis,  although 
something  may  be  done  in  the  way  of  symptomatic 
treatment.  Rest  must  be  enjoined  in  all  cases  and 
vascular  excitement  controlled  by  the  ice  bag  to 
the  precordia  and  the  use  of  aconite.  Heart  fail- 
ure calls  for  strychnin  and  alcoholic  stimulants, 


114  biSEASES   OF   tHE   MEARfj 

■while  digitalis  is  positively  contra-indicated,  the 
drug  causing  violent  cardiac  contractions  of  an  in- 
flamed and  enfeebled  heart.  In  the  malignant 
form  of  endocarditis,  antistreptococcus  serum 
promises  to  be  of  some  value. 

Chronic  Valvular  Disease. 

AORTIC    incompetency;    AORTIC    INSUFFICIENCY; 
AORTIC  REGURGITATION. 

General  Symptoms.  If  perfect  compensation 
exists,  there  may  be  no  symptoms.  Arterial 
anemia,  especially  of  the  brain,  is  an  early  symp- 
tom and  the  patient  complains  of  attacks  of  giddi- 
ness, is  pale  and  suffers  from  dyspnea.  Pains  in 
the  region  of  the  precordia  and  radiating  to  the 
neck  and  arms  occur  more  often  in  this,  than  in 
any  other  valvular  lesion  of  the  heart. 

Physical  Signs.  They  are  made  up  of  the  evi- 
dence furnished  by  hypertrophy  of  the  left  ven- 
tricle, viz.,  dislocation  of  the  heart  apex,  down- 
ward outward  and  to  the  left,  increased  area  of 
cardiac  impulse,  increased  area  of  cardiac  dullness, 
which  is  greater  than  in  any  other  valve  lesion, 
and  which  is  increased  downward  and  to  the  left. 
The  chief  sign  of  this  lesion  is  obtained  by  auscul- 
tation; at  the  second  right  costal  cartilage  a  dias- 
tolic murmur  is  heard. 

CHARACTERISTICS  OF  THE  MURMUR  OF  AORTIC  IN- 
COMPETENCY. 

1.  It  is  propagated  along  the  sternum  toward 


ENDOCARDITIS  AND   BHRONIC   VALVULAR   DISEASE.       llS 

the  apex.  2.  Its  point  of  maximum  intensity  may 
be  the  foip-th  left  costal  cartilage  on  the  apex.  3. 
It  may  be  heard  in  the  vessels  of  the  neck.  4. 
The  murmur  is  usually  soft,  but  sometimes  rough 
and  loud.  5.  A  systolic  murmur  heard  in  the 
aortic  area  is  not  diagnostic  of  aortic  stenosis,  it 
is  more  often  caused  by  roughening  of  the  semi- 
lunar valves  or  of  the  inner  coating  (intima)  of 
the  aorta.  6.  A  systolic  murmur  heard  in  the 
mitral  area,  associated  with  aortic  regurgitation 
may  be  caused  by  relative  insufficiency  of  the 
mitral  opening. 

Arterial  Signs.  The  peripheral  vessels  pulsate 
more  often  in  this  than  in  any  other  valve  lesion. 
Double  murmurs  may  be  heard  over  the  carotids 
and  subclavians.  The  water  hammer  or  Corrigan 
pulse  is  characteristic,  a  quick  and  jerking  pulse 
which,  striking  the  finger,  rapidly  recedes.  This 
pulse  phenomenon  is  accentuated  when  the  arm  is 
elevated.  The  capillary  pulse  is  obtained  by  draw- 
ing a  line  with  the  finger  nail  across  the  forehead. 
The  hyperemia  induced  on  either  side  of  the  line, 
becomes  alternately  red  and  pale.  It  is  also  seen 
beneath  the  finger  nails. 

Course  and  Termination.  The  lesion  may  be 
compensated  for  years  without  inconvenience. 
The  occurrence  of  heart  degeneration  marks  the 
advent  of  disturbed  compensation,  beginning  with 
precordial   pain,    headache,    vertigo,    palpitation, 


116 


DISEASES    OF   THE   HEART. 


cardiac  distress,  edema  and  dyspnea.  General 
dropsy  is  not  common  unless  a  mitral  lesion  com- 
plicates the  trouble.  Sudden  death  is  more  fre- 
quent in  this,  than  in  other  lesions.  With 
compensation  failure,  slight  irregular  fever  and 
embolic  phenomena  due  to  recurring  endocarditis 
terminate  the  scene. 

AOKTIC   STENOSIS 

General  Symptoms.  Owing  to  narrowing  of  the 
aortic  orifice  the  deficient  systemic  blood  supply 
induces  most  frequently  signs  of  cerebral  anemia. 

The  physical  signs  are  those  common  to  left 
ventricular  hypertrophy.  Palpation  may  de- 
tect a  systolic  thrill  in  the  aortic  area.  Ausculta- 
tion reveals  a  murmur  in  the  aortic  area,  systolic 
in  time  and  transmitted  along  the  course  of  the 
blood  vessels.  The  murmur  is  harsh,  loud  and 
sometimes  musical.  The  second  sound,  if  re- 
gurgitation is  not  present  may  be  muffled  or 
absent.  This  is  caused  by  stiffness  or  thickening 
of  the  valve. 

Diagnosis.  A  systolic  murmur  in  the  aortic 
area  may  also  be  caused  by  atheroma  or  dilatation 
of  the  aorta,  or  anemia.  A  murmur  due  to  the 
first  causes  is  often  accompanied  by  a  second  sound 
which  is  accentuated  and  the  small  and  slow  pulse 
and  systolic  thrill  are  absent.  The  murmur  of 
anemia  is  also  accompanied  by  an  accentuated  sec- 


ENDOCARDITIS  AND   CHRONIC   VALVULAR   DISEASE.       117 

ond  tone  and  there  is  no  hypertrophy ;,  thrill,  or 
small  pulse.     Signs  of  anemia  are  present. 

Course.  If  hypertrophy  is  present,  the  condi- 
tion may  be  latent.  The  early  signs  of  compensa- 
tion failure  are :  Dizziness,  pain  in  the  precordia 
and  palpitation. 

MITRAL    incompetency;    miteal    eegurgita- 
tion;  mitral  insufficiency. 

General  S}Tnptoms.  The  effects  of  this  lesion 
on  the  pulmonic  and  systemic  circulation  after 
failure  of  compensation  is  more  pronounced  than 
disease  at  any  of  the  other  orifices.  As  in  other 
lesions,  there  are  no  symptoms  if  the  trouble  is 
compensated.  When  compensa;tion  fails,  we  have 
all  the  characteristic  symptoms  of  heart  disease, 
cyanosis,  dyspenea,  cough  and  expectoration, 
dropsies,  etc. 

The  physical  signs  are  those  of  dilatation  and 
hypertrophy  of  both  chambers  at  the  time  of  full 
compensation.  Auscultation  exists  in  the  mitral 
area,  a  murmur  systolic  in  time,  transmitted  to  the 
left  axilla  and  scapular  angle.  In  accordance 
with  hypertrophy  of  the  right  ventricle  and  conse- 
quent increased  tension  in  the  pulmonary  artery, 
we  hear  accentuation  of  the  second  pulmonic  tone. 

Diagnosis.  The  systolic  murmur  of  aortic 
stenosis  and  tricuspid  regurgitation  may  be  mis- 
taken for  mitral  incompetency.       The  following 


116  DISEASES   OF   THE   HEART. 

data  speaks  for  aortic  stenosis:  The  murmur  is 
loudest  over  the  base  and  is  transmitted  to  the  ves- 
sels of  the  neck,  there  is  no  accentuation  of  the 
second  pulmonic  tone,  the  left  ventricle  only  is  en- 
larged, the  thrill  if  palpable  is  at  the  base  of  the 
heart.  In  tricuspid  regurgitation,  we  have  pul- 
sation of  the  cervical  veins,  pulsation  of  the  liver, 
and  the  systolic  murmur  has  its  seat  of  maximum 
intensity  at  the  base  of  the  ensiform  cartilage;  the 
propagation  of  the  murmur  is  not  so  extensive  nor 
in  the  direction  of  the  murmur  of  mitral  incom- 
petency. We  must  also  exercise  care  in  dis- 
tinguishing functional  murmurs  from  the  murmur 
of  incompetency. 

MITRAL  STENOSIS. 

General  Symptoms.  Constriction  of  the  left 
auriculo-ventricular  orifice  may  exist  for  years 
without  symptoms,  although  at  any  time  a  fresh 
endocarditis  may  develop  and  give  rise  to  the 
phenomena  of  embolism  in  the  brain  or  viscera. 

The  physical  signs  are  pathognomonic  of  this 
lesion  provided  compensation  exists.  The  brunt 
of  the  burden  is  borne  by  the  right  auricle  and 
ventricle  which  become  hypertrophied.  The  left 
ventricle  does  not  participate  in  the  cardiac 
changes. 

Inspection.  In  children,  rarely  in  adults,  the 
hypertrophied  right  ventricle  manifests  its  pres- 
ence by  bulging  of  the  lower  sternum  and  fifth  and 


ENDOCARDITIS    AND    CHRONIC    VALVULAR   DISEASE.        119 

sixth,  left  costal  cartilages.  The  apex  beat  is  only 
slightly  displaced. 

Palpation.  As  a  rnle  a  pronounced  fremitus  or 
thrill  is  felt  in  the  fourth  or  fifth  interspace  within 
the  nipple  line.  This  thrill  is  characteristic  and 
may  be  the  only  reliable  sign  of  the  lesion.  The 
thrill  is  rough  and  gratings  limited  in  area  and 
culminates  in  a  sharp  sudden  shock.  The  cardiac 
impulse  is  felt  in  the  third  and  fourth  interspaces 
and  is  due  to  an  enlarged  right  ventricle. 

Percussion  yields  increased  dullness  to  the  right 
of  the  sternum  and  increased  dullness  upward  as 
high  as  the  second  rib. 

Auscultation.  In  the  mitral  area^  usually 
limited,  a  murmur  of  a  churning  and  grinding 
character  is  heard  which  is  synchronous  with  the 
thrill  and  terminates  with  a  loud  shock  that  is 
heard  at  the  same  time  as  the  first  sound.  Like 
the  thrill,  this  murmur  is  pathognomonic.  This 
murmur  is  the  presystolic  murmur,  occuping  the 
entire  period  of  diastole  or  more  often  the  latter 
half  of  this  phase.  The  second  pulmonic  sound  is 
accentuated.  The  pulse  is  smaller  in  volume  than 
normal,  but  regular. 

There  are  associated  murmurs,  chief  of  which  is 
the  mitral  systolic,  as  stenosis  rarely  occurs  without 
some  incompetence  of  the  valve.  A  tricuspid 
systolic  murmur  may  be  present  owing  to  relative 
insufficiency  of  that  valve. 


120  DISEASES   OF   THE  HEART. 

TEicuspiD  incompetency;   teicuspid  eegukgi- 

TATION. 

This  rarel}'  occurs  as  a  result  of  valvular  endo- 
carditis. As  a  rule,  it  is  a  relative  insufficiency 
superinduced  by  dilatation  of  the  right  ventricle, 
secondary  to  lesions  of  the  valves  on  the  left  side  or 
pulmonary  diseases,  causing  obstruction  to  the  cir- 
culation. 

The  symptoms  are  mainly  revealed  by  physical 
signs  and  are  made  up  of  phenomena  associated 
with  obstruction  in  the  pulmonary  circulation  and 
systemic  veins. 

Diagnosis.  1.  Pulsation  of  the  veins  of  the 
necks,  caused  by  systolic  regurgitation  of  blood 
into  the  right  auricle  and  the  transmission  of  the 
pulse  wave  into  the  cervical  veins.  The  right 
jugular  vein  pulsates  more  forcibly  than  the  left. 
Eegurgitation  into  the  vein  is  associated  with  the 
pulsation.  To  observe  the  phenomenon  of  regur- 
gitation, empty  the  external  vein  by  pressing  on 
the  same  just  above  the  clavicle  and  moving  it 
along  the  vein  in  the  direction  of  the  lower  jaw. 
Thus  emptied,  with  each  cardiac  systole,  it  will 
be  observed  to  fill  up  from  below. 

Eegurgitant  pulsation  may  be  transmitted  to  the 
inferior  vena  cava  and  thence  to  the  hepatic  veins, 
causing  hepatic  venous  pulsation.  Hepatic  pul- 
sation is  best  felt  by  bimanual  palpation,  one  hand 
over  the  fifth  and  sixth  costal  cartilages  and  the 


ENDOCARDITIS   AND   CHRONIC   VALVULAR   DISEASE.       121 

other  over  the  liver  in  the  axillary  region.  2. 
A  systolic  murmur  in  the  tricuspid  area.  It  is 
usually  soft,  and  blowing  and  may  be  absent.  Per- 
cussion shows  increased  cardiac  dullness  to  the 
right  of  the  sternum. 

TEICUSPID  STENOSIS. 

Very  rare  and  usually  fatal  in  origin.  Other 
congenital  lesions  may  mask  its  presence.  The 
physical  signs  are  those  of  mitral  stenosis,  with 
transference  of  the  signs  to  the  right  side.  Ex- 
treme cyanosis  is  common  and  dropsy  extreme.  A 
positive  diagnosis  is  rarely  made  owing  to  its  as- 
sociation with  other  lesions. 

PULMONARY  VALVE  LESIONS. 

Stenosis  is  one  of  the  rarest  of  acquired  lesions, 
but  the  most  frequent  of  the  congenital  heart  af- 
fections. The  congenital  lesion  is  associated 
usually  with  patency  of  the  ductus  Botalii  and  de- 
fect of  the  ventricular  septum.  Cyanosis  and 
dyspnea  are  extreme.  Auscultation  shows  a  sys- 
tolic murmur  in  the  second  left  interspace. 

Insufficiency.  Like  the  foregoing  it  is  usually 
congenital,  but  may  arise  from  endocarditis  or  be 
merely  relative  from  dilatation  of  the  pulmonary 
artery  at  its  origin.  The  murmur  replaces  the 
second  pulmonic  sound,  and  its  intensity  is  in- 
creased during  expiration.  There  is  hypertrophy 
and  dilatation  of  the  right  ventricle. 


123  DISEASES   OF   THE   HEART. 

COMBINED  VALVULAK  LESIONS. 

In  more  than  one-half  of  all  the  eases  of  cardiac 
valvular  lesions,  combined  murmurs  are  present. 
Stenosis  of  a  valve  is,  as  a  rule,  combined  with  in- 
sufficiency of  the  same  valve.  Thus  aortic  stenosis 
and  insufficiency  coexist,  but  one  may  for  a  time 
compensate  the  other  so  that  only  the  evidence  of 
one  lesion  is  demonstrable.  Such  a  lesion  as  the 
one  just  cited  would  act  as  follows :  The  stenosis 
diminishes  the  regurgitated  quantity  of  blood  from 
the  aorta  into  the  left  ventricle,  Eelative  insuf- 
ficiency of  the  mitral  valve  sequential  to  aortic 
insufficiency  counteracts  overfilling  of  the  left 
ventricle  and  also  over-distension  of  the  aorta. 

A  relative  tricuspid  insufficiency  secondary  to 
mitral  disease  may  be  doubly  interpreted.  Such  a 
lesion  may  be  speedily  fatal  owing  to  over-disten- 
sion of  the  general  venous  circulation,  or  it  may 
prove  salutary  because  it  may  relieve  the  right 
ventricle  of  its  surplus  of  blood.  The  combined 
valvular  lesions  in  order  of  frequency  are:  1. 
Mitral  and  aortic  segments.  2.  Mitral  and  tri- 
cuspid lesions.     3.  Aortic,  mitral  and  tricuspid. 

Aortic  insufficiency  or  aortic  stenosis  exists  more 
frequently  in  combination  with  mitral  insufficiency 
than  aortic  stenosis  with  mitral  stenosis  or  mitral 
stenosis  with  aortic  insufficiency.  The  most  fre- 
quent association  in  adults  is  mitral  insufficiency 
with  slight  aortic  stenosis,  whereas  in  children  ihQ 


ENDOCARDITIS  AND   CHRONIC   VALVULAR  DISEASE.       123 

most  common  association  is  aortic  and  mitral  in- 
sufficiency. 

DIAGNOSIS. 

Valvular  lesions  are  not  difficult  of  location, 
even  though  several  murmurs  coexist,  provided 
compensation  is  present.  The  average  duration  of 
compensation,  hased  on  a  study  of  102  cases  by 
Eomberg,  has  been  found  to  be  seven  years. 
Sooner  or  later  compensation  fails  and  the  heart 
becomes  rapid  and  irregular  with  faint  sounds  and 
murmurs,  a  condition  spoken  of  as  delirium  cordis. 
When  this  heart  delirium  occurs  it  is  almost  im- 
possible to  correctly  time  the  murmurs.  Eegula- 
tion  of  the  cardiac  action  with  digitalis  and  phy- 
sical rest  may  prove  of  advantage,  but  until  some 
regulation  is  established  it  is  often  impossible  to 
make  a  correct  diagnosis. 

Differentiation  of  contemporaneous  murmurs 
may  be  possible  by  percussion,  auscultation  and  the 
inhibition  maneuver.  The  secondary  changes  in 
the  myocardium  usually  coincides  with  the  pre- 
dominating murmur.  If  auscultation  determines 
two  murmurs  of  different  character,  one  blowing 
and  the  other  rough,  two  distinct  murmurs  exist. 
If  again,  we  hear,  let  us  say,  a  murmur  at  the  apex 
and  another  at  the  aorta,  auscultate  step  by  step 
from  one  situation  to  the  other.  If  it  is  every- 
where audible,  but  becomes  louder  toward  one 


124  DISEASES   OF   THE   HEART. 

point,  then  its  origin  is  at  the  latter  situation  and 
is  conveyed  to  the  other. 

The  inhibition  maneuver  described  in  the  chap- 
ter on  Diagnosis  is  an  invahiable  aid  in  causing 
transmitted  murmurs  to  disappear  to  be  replaced 
by  tones.  The  maneuver  should  only  he  attempted 
after  forced  expiration,  for  when  the  lungs  are  in- 
flated all  endocardial  murmurs  are  naturally 
weakened. 

CONGENITAL  HEAET  DISEASE. 

The  most  frequent  lesion  is  stenosis  of  the  pul- 
monary orifice,  associated  very  often  with  imper- 
fections of  the  ventricular  septum  and  patency  of 
the  foramen  ovale  and  ductus  arteriosus.  In  86 
per  cent  of  patients  with  congenital  heart  disease 
living  beyond  the  twelfth  year,  according  to  Pea- 
cock, the  lesion  is  at  the  pulmonary  orifice. 

Symptoms.  Cyanosis  is  the  chief  symptom  in 
over  ninety  per  cent  of  the  cases,  hence  the  terms 
"blue  disease"  and  "morbus  ceruleus,"  which  are 
other  names  for  congenital  heart  disease.  The 
lividity  appears  in  the  first  week  of  life.  The  skin 
may  be  universally  purple  or  may  be  confined  to 
the  fingers,  lips,  nose  and  ears.  It  is  increased  by 
exertion.  Dyspnea  and  cough  are  common.  Phy- 
sical development  is  retarded  and  the  mind  is 
sluggish.  Clubbing  of  the  fingers  and  toes  is  a 
common  occurrence. 

Diagnosis.     Cyanosis  in  children  with  or  with- 


ENDOCARDITIS   AND   CHRONIC   VALVULAR   DISEASE.       125 

out  enlargement  of  the  heart,  together  with  a  mur- 
mur during  the  early  weeks  of  life,  is  due  to  con- 
genital heart  disease. 

Prognosis.  More  than  one-half  the  patients  die 
before  the  end  of  the  first  year,  and  not  less  than 
three-fourths  before  the  end  of  the  third  year. 

MYOCARDITIS. 

Inflammation  of  the  myocardium  may  be  acute 
or  chronic.  Etiology.  The  acute  specific  fevers 
due  to  the  infectious  element.  The  chronic  va- 
riety is  associated  with  atheroma,  and  frequently 
complicates  chronic  Bright's  disease. 

The  acute  form  may  result  in  dilatation  of  the 
heart,  fatty  heart  or  aneurism  of  the  heart.  The 
chronic  form  may  result  similarly. 

Symptoms.  The  diagnosis,  myocarditis  is  made 
more  often  by  the  pathologist  than  the  clinician 
for  the  symptomatology  of  the  disease  is  vague  and 
uncertain.  If  in  the  course  of  an  acute  specific 
fever,  precordial  oppression,  dyspnea  and  syncope 
occur  and  if  to  these  symptoms,  we  add  a  rapid 
and  weak  pulse,  signs  of  cardiac  enfeeblement  and 
the  physical  signs  pertinent  thereto,  we  may  sus- 
pect myocarditis. 

The  recognition  of  cardiac  aneurism  is  made 
possible  by  careful  percussion  of  the  heart.  The 
latter  sign  shows  a  projection  beyond  the  line  of 
cardiac  dullness.  With  the  Eoentgen  rays,  I  was 
able  in  one  patient  to  trace  with  accuracy  the  ir- 


126  DISEASES    OF    THE    HEART. 

regular  outline  of  the  heart  and  the  diagnosis  was 
confirmed  at  the  necropsy,  death  having  occurred 
suddenly  after  exertion  from  rupture  of  the  heart, 
a  frequent  sequel  in  cardiac  aneurysm. 

Treatment.  Absolute  physical  rest  and  proper 
feeding  are  indicated.  jSTo  drug  beyond  the  use  of 
strychnin  is  of  advantage.  Iodide  of  potash 
long  continued  is  said  to  promote  the  nutrition  of 
the  heart.  The  ISTauheim  system  of  baths  and  re- 
sisted movements  have  given  me  marvelous  re- 
sults in  a  few  cases.  In  some  instances  the  move- 
ments have  been  harmful.  It  is  difficult  to  define 
indications  for  the  baths  and  movements,  the  con- 
traindications are  evidenced  by  the  results  of  such 
treatment. 

FATTY  HEART. 

Two  pathologically  distinct  affections  must  be 
differentiated :  1,  fatty  degeneration  in  which  the 
muscle  fibers  of  the  heart  have  been  transformed 
into  fat,  and  2,  fatty  overgrowth  in  which  the 
normal  epicardial  fat  is  increased  in  amount. 

PATTY  DEGENERATION. 

Etiology.  Nutritional  disturbances  of  old  age 
and  the  wasting  diseases.  Infectious  fevers, 
chronic  anemia,  arsenical  and  phosphorus  poison- 
ing, diseases  of  the  coronary  arteries  and  finally 
as  a  secondary  lesion  in  cardiac  hypertrophy. 

Symptoms.  Diagnosis  is,  as  a  rule,  obscure. 
The  chief  sisrn  is  cardiac  enfeeblement.     Cardiac 


ENDOCARDITIS   AND   CHRONIC   VALVULAR   DISEASE.        127 

asthma,  angina  pectoris,  pseudo-apoplectic  at- 
tacks and  pulse  retardation  (30-40  beats  per  min- 
ute) are  relatively  frequent.  .  Cheyne-Stokes 
breathing  and  the  fatty  arcus  senilis,  formerly  re- 
garded as  pathognomonic,  are  untrustworthy. 

FATTY  OVERGROWTH. 

An  increase  of  subpericardial  fat  is  usually  a 
manifestation  of  general  obesity.  The  recognition 
of  the  condition  is  based  on  the  general  obesity 
associated  with  signs  of  heart  failure,  viz. :  Asthma, 
syncopal  attacks,  bronchitis  with  weak  and  muffled 
heart  sounds.  Sudden  death  occurs  from  syncope 
or  from  rupture  of  the  heart. 

Treatment.  The  treatment  of  fatty  degenera- 
tion is  strictly  symptomatic.  Fatty  overgrowth 
is  greatly  benefited  by  the  method  of  Oertel  re- 
ferred to  under  general  treatment  as  well  as  by 
the  Sehott  method. 


CHAPTER  VI. 

NEUROSES   OF   THE   HEART. 

The  rapidity  and  force  of  cardiac  action  are 
regulated  by  the  pneumogastric  or  vagus  nerve 
which  inhibits  it  and  the  sympathetic  which  ac- 
celerates it.  In  the  heart  the  blood  pressure  is 
regulated  by  a  branch  of  the  vagus,  the  depressor 
nerve,  which  acts  by  causing  sudden  dilatation  of 
the  large  abdominal  vessels  to  lessen  cardiac  pres- 
sure or  by  constricting  them  to  raise  it.  The  vaso 
motor  system  of  nerves  regulates  the  caliber  and 
tone  of  the  blood  vessels.  It  is  connected  with  the 
heart,  so  that  tension  of- the  arteries  and  force  of 
the  cardiac  pulsations  are  regulated  with  each 
other. 

The  coronary  arteries  are  the  nutrient  vessels 
of  the  heart.  They  arise  from  the  aorta  imme- 
diately behind  the  valve  and  their  blood  is  re- 
turned by  a  vein  to  the  right  auricle,  where  its 
opening  is  guarded  by  a  little  valve. 

GENEKAL  ETIOLOGY. 

Largely  reflex  from  the  stomach  and  intestines. 
Peripheral  irritation  of  the  gastric  branches  of  the 
vagus  by  the  products  of  indigestion  is  a  fruitful 
cause.     How  this  irritation  is  induced  is  as  yet 


NEUROSES  OF  THE  HEART.  129 

a  conjectural  matter,  although  we  do  know  that 
when  treatment  is  directed  toward  the  relief  of  a 
gastric  affection  cure  is  often  attained. 

The  absorption  of  substances  from  the  intestinal 
tract  which  are  the  result  of  bacterial  activity, 
must  also  be  taken  into  consideration,  and  while 
we  possess  no  means  of  demonstrating  such  prod- 
ucts in  the  circulation  we  assume  that  they  exist 
owing  to  the  good  results  following  treatment. 
Cleansing  the  intestinal  tract  is  often  a  herculean 
undertaking,  but  like  the  fabled  stables  of  Augeas 
our  endeavors  must  be  more  in  the  direction  of 
asepsis  than  antisepsis. 

The  genito-urinary  apparatus  of  both  sexes  is 
frequently  implicated  in  the  etiology  of  cardiac 
neuroses  and  demand  careful  investigation.  A 
similar  statement  is  apposite  with  reference  to 
the  naso-pharynx.  Anemia  is  a  common  cause 
and  so  is  the  inordinate  use  of  alcohol,  tea,  cof- 
fee and  tobacco.  Mental  excitement,  depression 
or  emotion  is  a  causative  factor. 

In  a  number  of  individuals  no  etiologic  factor 
beyond  a  neurasthenic  condition  may  be  demon- 
strated, and  it  would  appear  in  these  cases  as  if 
the  cardiac  apparatus  bore  the  brunt  of  the  in- 
sanity of  the  nervous  system  representing,  as  it 
were,  the  locus  minoris  resistentiae.  At  any  rate 
I  have  known  the  most  intractable  cardiac  neu- 
roses yield  to  a  thorough  rest  cure. 


130  DISEASES   OF   THE   HEART. 

I.  Palpitation. 
This  term  is  applied  to  conscious  cardiac  con- 
tractions of  the  heart  of  increased  force  asso- 
ciated with  a  disturbance  of  rh5i;hni  and  sometimes 
with  distress  in  the  precordia,  dyspnea  and  anxie- 
ty. Besides  the  factors  previously  mentioned  in 
the  general  etiology,  the  nervous  phenomenon  may 
be  associated  with  organic  heart  disease,  although 
this  is  infrequent.  The  irritable  heart  described 
by  Da  Costa,  common  among  the  young  soldiers 
during  the  Civil  war,  is  a  similar  neurosis.  Two 
facts  were  concerned  in  its  causation,  mental  ex- 
citement and  excessive  muscular  exertion. 

DIAGNOSIS. 

Visible  cardiac  pulsations  against  the  chest  wall, 
pulse  120-160  per  minute  and  loud  cardiac  tones 
are  practically  the  objective  symptoms  of  a  par- 
oxysm which  may  last  from  a  minute  to  an  entire 
day.  A  mild  paroxysm,  often  the  result  of  indi- 
gestion, is  attended  by  a  slight  fluttering  of  the 
heart  and  a  sensation  which  the  patient  describes 
as  a  "goneness."  The  diagnosis  of  nervous  palpi- 
tation should  only  be  made  when  careful  exami- 
nation of  the  heart  reveals  no  evidence  of  organic 
disease.  A  murmur  must  not  be  construed  as  evi- 
dence, insomuch  as  it  is  often  hemic,  and  anemia 
is  largely  concerned  in  the  causation  of  the  neu- 
rosis. 


NEUROSES   OF  THE   HEART.  131 

TKEATMENT. 

Suggestion  plays  an  important  role.  Convince 
the  patient  that  the  trouble  is  purely  functional 
and  half  the  battle  is  won.  To  logically  carry  out 
this  suggestion  medicines  are  contra-indicated;  as 
much  may  be  effected  by  hygienic  measures.  Reg- 
ulating the  methods  of  living,  careful  dieting, 
avoidance  of  alcohol,  coffee,  tea  and  tobacco,  in- 
terdicting sexual  excitement  and  mental  excite- 
ment, bowel  regulation  and  a  modified  rest  cure 
are  a  few  hygienic  regulations. 

The  paroxysm  of  palpitation  may  be  arrested 
by  certain  mechanic  manipulations,  especially  in 
hysterical  persons,  by  pressure  on  the  vagus  in  the 
neck  and  certain  hysterogenic  zones  on  the  abdo- 
men, particularly  the  ovarian  region.  Eest  in  bed 
and  an  ice  bladder  to  the  precordia  may  also  be 
tried.  The  bromides,  valerian,  camphor  and  hyos- 
cyamus  may  prove  beneficial,  but  the  most  effect- 
ive remedy  is  unquestionably  morphin  when  given 
hypodermieally.  Eecurrent  paroxysms  may  be 
prevented  by  observing  indications  for  therapeutic 
measures,  the  treatment  of  anemia,  hysteria,  ma- 
laria, gout  and  the  uric  acid  diathesis.  Galvanism 
of  the  vagus  is  sometimes  beneficial.  The  con- 
tinued use  of  tincture  of  nux  vomica  in  large  doses 
is  particularly  valuable.  One  of  my  patients,  a 
physician,  suffering  from  palpitation  for  ten  years, 
found  almost  immediate  and    permanent    relief 


182  DISEASES   OF   THE   HEART. 

from  the  Schott  methods  of  resistance  exercises 
and  baths. 

II.  Paeoxysmal  Tachtcaedia  (Eapid  Heaet). 

This  is  a  paroxysmal  affection  variable  in  dura- 
tion, associated  with  a  feeling  of  great  anxiety,  in 
which  the  number  of  pulse  beats  may  reach  150 
or  more.  Two  forms  have  been  described,  neurotic 
and  symptomatic  tachycardia.  The  causes  of  the 
former  variety  are  the  same  as  in  palpitation.  The 
S3rmptomatic  variety  may  be  due  to  central  and 
peripheral  causes. 

Central  causes :  lesions  of  the  brain  and  cord. 

Peripheral  causes :  tumors,  aneurisms,  enlarged 
lymph  glands  which  compress  the  vagus  and  neu- 
ritis of  the  vagus. 

The  rapid  heart  is  directly  dependent  upon  eith- 
er paralysis  of  the  vagus  or  stimulation  of  the 
sympathetic  nerves.  Fraentzel  suggested  that  the 
cause  could  be  ascertained  by  digitalis  and  mor- 
phin.  If  the  vagus  were  at  fault  the  former  drug 
would  prove  effective,  whereas  if  the  sympathetic 
were  at  fault  morphin  would  prove  useful. 

DIAGXOSIS. 

Heart  hurry  is  characterized  by  paroxysms  of  a 
high  pulse  rate  (in  one  of  my  patients  300  beats 
per  minute)  without  a  palpable  cause,  dissociated 
with  any  cardiac  anomaly  in  the  inter-paroxysmal 
periods.    Nothnagel  decides  that  a  great  increase 


NEUROSES  OF  THE  HEART.  133 

in  the  pulse  frequency,  accompanied  by  a  weak 
heart  beat,  speaks  for  paralysis  of  the  vagus, 
whereas  a  strong  impulse,  fullness  of  the  periph- 
eral arteries  with  high  tension  is  in  favor  of 
stimulation  of  the  accelerators.  This  condition 
must  not  be  confounded  with  a  normally  rapid 
pulse  nor  with  an  increased  pulse  rate  occurring 
in  certain  pathologic  conditions. 

TEEATMENT. 

The  same  general  methods  recommended  in  the 
treatment  of  palpitation  are  here  applicable. 
Digitalis  has  been  serviceable,  but  no  dependence 
can  be  placed  on  its  action.  Subjugation  of  the 
paroxysm  of  tachycardia  may  be  accomplished  by 
galvanization  of  the  vagus  (positive  pole  under 
angle  of  Jaw,  negative  pole  lower  down  over  each 
side  of  neck).  In  a  case  reported  by  IsTothnagel, 
attacks  were  jugulated  by  deep  inspirations. 
Eosenfeld's  patient  controlled  her  attack  by  going 
to  bed,  raising  her  head  with  her  feet  planted 
firmly  against  the  foot  of  the  couch,  and  then 
taking  a  forced  inspiration  she  pressed  down  with 
all  her  might,  with  the  object  of  closing  the  glottis. 
Schott  warmly  recommends  his  balneologic  and 
gymnastic  methods.  The  long-continued  use  of 
iodide  of  potash  proved  curative  in  one  of  my 
patients.  A  colleague  controlled  his  attacks  with 
digitalis.     He  had  tried  twelve  preparations  of 


134  DISEASES  OF  THE  HEART. 

the  tincture  from  as  many  different  drug  stores 
without  any  result.  A  thirteenth  preparation 
from  an  homeopathic  pharmacy  was  succcessful. 

III.  Brachtcaedia  (Bradtcaedia — Slow 
Heaet). 

Slowness  of  the  pulse  may  be  physiologic.  Na- 
poleon had  a  pulse  of  only  40  per  minute.  Before 
deciding  whether  brachycardia  really  exists  it  is 
necessary  to  determine  if  the  arterial  and  heart- 
beats correspond,  for  while  the  cardiac  pulsations 
may  be  70  only  30  beats  reach  the  radial  pulse, 
therefore  the  cardiac  contractions  and  not  the 
pulse  beats  should  be  counted.  Riegel's  classifi- 
cation of  brachycardia  is  the  one  usually  accepted. 

Physiologic  brachycardia. — In  the  puerperal 
state  a  slow  pulse  is  a  common  manifestation  when 
it  may  reach  a  rate  as  low  as  34. 

Pathologic  brachycardia  is  present  in  conva- 
lescence from  acute  fevers,  notably  rheumatism, 
diphtheria,  pneumonia  and  typhoid  fever.  The 
cause  is  most  probably  resident  in  the  heart  muscle 
and  not  dependent  on  exhaustion  as  maintained  by 
Traube. 

Diseases  of  the  digestive  organs  was  the  chief 
etiologic  factor  in  Riegel's  cases.  Diseases  of  the 
lungs. — In  valvular  heart  lesions  it  is  not  com- 
mon, although  in  degeneration  of  the  heart  muscle 
it  is  frequent.    Cases  of  fatty  heart  have  been  ob- 


NEUROSES   OF  THE   HEART.  135 

served  where  the  pulse  rate  was  only  13  per  min- 
ute^,  and  this  rate  was  maintained  for  years.  Ne- 
phritis, toxic  agents,  diabetes,  anemia,  diseases  of 
the  cord  and  brain  are  regarded  as  other  causes. 
Brachycardia  arising  reflexly  from  some  dis- 
turbance in  the  gastro-enteric  tract  is  easily  under- 
stood when  we  remember  how  readily  the  inhib- 
itory action  of  the  vagus  may  be  excited  through 
this  channel.  In  diseases  of  the  heart,  brain  and 
kidneys  it  is  often  an  ominous  sign.  It  is  often  a 
symptom  in  uremia.  Muscarin  and  the  biliary 
salts  can  produce  a  slow  pulse.  Eapid  resorption 
of  large  quantities  of  bile  not  only  slows  the  pulse 
but  makes  the  heart  action  irregular.  Thus,  in 
catarrhal  icterus  a  slow  pulse  is  a  common  occur- 
rence. 

SYMPTOMS. 

During  a  paroxysm.  Syncopal  attacks  occur  and 
the  patient  may  remain  unconscious  for  hours. 
During  the  attack  the  heart  impulse  and  sounds 
are  feeble.  Sudden  death  may  terminate  an  at- 
tack. 

TREATMENT. 

Eest  is  essential.  The  treatment  is  mainly 
symptomatic,  although  a  thorough  examination 
may  often  determine  a  causal  condition,  the  re- 
moval of  which  cures  the  affection.  To  excite  the 
action  of  the  heart  in  a  paroxysm,  caffein,  strych- 
nin and  nitro-glycerin  may  successively  be  tried. 


136  DISEASES   OF   THE   HEART. 

IV.  Arrhythmia  (Irregular  Heart). 
An  irregular  heart  may  be  clinically  manifested 
as  an  intermission  when  one  or  more  beats  of  the 
heart  are  dropped,  or  as  an  irregularity  when  the 
beats  show  inequality  in  volume  and  force.  Ar- 
rythmical  action  is  expressed  by  the  following  well 
recognized  varieties  of  pulse: 

1.  The  paradoxical  pulse,  in  which  during  in- 
spiration the  beats  are  more  rapid  though  less  full 
than  in  expiration.  It  attends  chronic  adhesive 
pericarditis  when  fibrous  bands  become  attached 
to  the  root  of  the  aorta.  It  may  be  felt  in  the 
sleeping  child. 

2.  Intermittent  pulse  signifies  a  missed  or 
dropped  beat.  This  intermittency  may  be  irreg- 
ular or  cyclic,  an  intermittence  occurring  at  every 
fourth,  sixth  or  eighth  beat. 

3.  The  alternate  pulse  is  expressed  by  alternate 
full  and  feeble  pulse  beats. 

4.  The  bigeminal  pulse  occurs  when  two  beats 
follow  each  other  quickly  and  the  next  two  not  so 
quickly,  three  such  beats  occurring  in  rapid  suc- 
cession gives  rise  to  the  trigeminal  pulse. 

5.  The  pulse  of  delirium  cordis  gives  rise  to 
marked  irregularity  and  inequality  of  the  pulse 
beats. 

Irregularity  of  heart  rhythm  may  give  no 
expression  in  the  pulse.  We  have  embryocardia 
or  fetal  heart  rhythm  in  which  shortening  of  the 


NEUROSES  OF  THE  HEART.  137 

long  pause  exists,  and  the  first  and  second  sounds 
as  in  the  fetal  heart  are  similar.  This  sign  is  of 
ominous  import  in  fevers,  indicating  a  weak  heart. 
Gallop  or  cantering  rhythm,  expressed  by  the  words 
*'rat  ta-tat,"  are  sounds  simulating  the  triple  foot- 
fall of  a  horse  at  canter.  Present  in  arterio- 
sclerosis, interstitial  nephritis  and  myocarditis. 
It  may  be  met  with  in  health, 

ETIOLOGY. 

The  causal  classification  of  Baumgarten  is  usu- 
ally accepted:  1.  Organic  cerebral  affections.  2. 
Eeflex  from  diseases  of  the  viscera.  3.  Toxic; 
tobacco,  coffee,  tea  and  from  such  drugs  as  digi- 
talis, belladonna  and  aconite.  4.  Changes  in  the 
heart. 

SIGNIFICANCE. 

Arrhythmia  may  exist  for  a  long  period  without 
symptoms.  It  is  usually  in  association  with  other 
cardiac  signs  that  its  presence  is  noted.  Asso- 
ciated with  myocardial  or  valvular  lesions  it  is 
ominous,  but  as  a  permanent  condition  secondary 
to  mental  influences  it  is  usually  without  signifi- 
cance. The  treatment  is  symptomatic. 
Angina  Pectoris  (Stenocardia — Breast  Pang, 

Cardiodynia)  . 

A  symptomatic  paroxysmal  affection  (described 
by  Heberden  as  the  breast  pang)  associated  with 
cardiac  lesions. 


138  DISEASES   OF   THE   HEART. 

ETIOLOGY  AND  PATHOLOGY. 

An  affection  of  adult  life  occurring  chiefly  in 
men.  Associated,  as  a  rule,  with  arterio-sclerosis, 
hypertrophy  of  the  heart  and  lesions  of  the  myo- 
cardium and  aorta.  No  hypotheses  yet  advanced 
suffice  to  account  for  its  symptomatology.  The 
hypotheses  thus  far  advanced  are :  1.  That  it  is 
a  neuralgia  of  the  cardiac  nerves.  2.  A  cramp  of 
the  heart  muscle  (Heberden).  3.  Extreme  ten- 
sion of  the  ventricular  walls  following  acute  dila- 
tation with  involvement  of  the  coronary  arteries 
(Traube).  4.  Spasm  of  the  coronary  arteries  with 
increased  intra-cardiac  pressure.  In  fatal  cases 
the  coronary  arteries  are  usually  diseased.  In  one 
of  my  patients  the  coronary  arteries  were  practi- 
cally calcareous  tubes,  yet  the  pulse  showed  no  evi- 
dence of  arterio-sclerosis  with  the  sphygmograph. 

SYMPTOMS. 

The  paroxysm  begins  suddenly,  usually  after 
some  exciting  cause.  There  is  agonizing  pain  in 
the  heart  region,  radiating  up  the  neck  and  down 
the  arms,  particularly  to  the  left  arm.  The  sen- 
sation is  one  of  impending  death  and  the  feeling 
one  as  if  the  heart  were  held  in  a  vise.  The  face 
is  pale  and  bathed  in  perspiration.  Dyspnea  is  not 
the  rule.  Little  or  no  changes  are  noted  in  the 
pulse  or  heart  during  an  attack.  The  paroxysm 
is  of  short  duration  (few  seconds  to  three  min- 


NEUROSES    OF    THE    HEART.  139 

Tites)  and  is  followed  by  eructations  of  gas,  vom- 
iting or  discharge  of  a  large  quantity  of  clear 
urine.  The  attacks  may  recur  at  intervals  of  from 
weeks  to  years.  The  chief  diagnostic  points  are: 
1.  Sudden  intense  pain  and  sense  of  impending 
death.  2.  Occurrence  in  men  between  the  ages  of 
40  and  60.  3.  Existence  of  arterio-sclerosis  char- 
acterized by  accentuated  second  aortic  tones  and 
pulse  of  high  tension.  I  can  recall  two  individ- 
uals who  for  years  suffered  from  slight  pains  in 
the  left  arm  with  numbness  in  the  hand  and  fin- 
gers who  eventually  died  in  a  typical  attack  of 
angina. 

A  variety  of  the  true  form  of  angina  has  been 
described  by  Nothnagel  as  angina  vasomotoria. 
This  form  follows  exposure  to  cold  and  is  charac- 
terized by  a  general  spasm  of  the  peripheral  ar- 
teries with  pallor  of  the  face  and  coldness  and 
stiffness  of  the  limbs.  The  chief  difficulty  in  diag- 
nosis is  to  differentiate  the  true  from  the  false  or 
Jiysterical  pseudo-angina.  The  chief  diagnostic 
signs  of  pseudo-angina  are :  1.  Occurrence  in 
hysterical  women  and  nearasthenic  men.  2.  Oc- 
currence at  every  age.  3.  Attacks  are  periodical, 
spontaneous  and  often  nocturnal  and  associated 
with  nervous  symptoms.  4.  Attack  lasts  from  a 
half  to  several  hours,  and  is  never  fatal.  5.  Asso- 
ciated with  extreme  restlessness  aii<i  eniotional 
symptoms, 


140  DISEASES    OF    THE    HEART. 

I  am  surprised  to  find  in  the  literature  very 
little  reference  to  a  dilated  stomach  as  the  cause 
of  pseudo-angina,  a  form  described  by  myself  as 
gastrectatic  pseudo-angma.  I  have  frequently  en- 
countered tills  affection  and  permanent  cures  have 
followed  treatment  directed  toward  the  stomach  by 


Fig.  II — Dull  area  in  dislocation  of  heart  upward  by 
a  dilated  stomach. 

a  suitable  dietary  and  lavage.     If    the    gastric 

trouble  is  provoked  by  neurasthenia,  the    latter 

condition  demands  treatment. 

In  a  previous  chapter  I  have  demonstrated  the 

facility  with  which  a  dilated  stomach  may  dislo- 


NEUROSES  OF  THE  HEART.  141 

cate  the  heart,  since  which  time  I  have  discovered 
a  new  and  trustv/orthy  sign  of  heart  dislocation 
consecutive  to  gastrectasis.  It  is  a  circumscribed 
area  of  dullness,  often  amounting  to  iiatness  in  the 
left  interscapular  region  between  the  internal  bor- 
der of  the  scapula  and  spine.     Over  the  dullness 


Fig.  12 — Same   case.     Area  of  dullness  increased 
patient  leaning  backward. 

bronchial  respiration  is  heard.    When  the  patient 

is  directed  to  lean  forward  the  dullness  disappears 

and  likewise  the  bronchial  breathing,  but  are  again 

in  evidence  when  the  erect  attitude  is  resumed. 

When  the  patient  is  directed  to  lean  backward  the 

area  of  dullness  is  very  much  increased. 


142  DISEASES   OF   THE   HEART 

This  phenomenon  is  caused  by  a  dislocated  heart 
compressing  the  lung,  which  fact  is  easily  demon- 
strated by  examination  with  the  Eoentgen  rays. 
The  foregoing  syndrome  I  have  reproduce^  syn- 
thetically by  distending  the  stomach  with  air,  thus 
proving  the  correctness  of  my  conclusions.  Iden- 
tical percussional  phenomena  may  be  observed 
when  the  heart  is  enormously  enlarged  upwards. 

The  prognosis  is  always  bad  in  true  angina,  al- 
though years  may  elapse  before  a  fatal  termina- 
tion, provided  excitement,  muscular  exertion  and 
dietetic  errors  are  avoided.  Vasomotor  angina  is 
less  grave  and  pseudo-angina  is  always  favorable. 
Cardiac  pain  without  evidence  of  arterio-sclerosis, 
or  valve  disease,  is  not  of  much  moment  (Osier). 

TREATMENT. 

A  quiet  life  should  be  encouraged.  Attacks  may 
be  curtailed  and  prevented  by  inhalations  of  ni- 
trite of  amyl,  perles  of  which  containing  3  to  5 
drops  should  be  constantly  carried  by  individuals 
thus  afflicted.  If  the  attack  is  not  controlled  one 
minim  of  the  1  per  cent  solution  of  nitro  glycerin 
should  be  given  hypodermically  and  repeated  every 
15  minutes  if  pain  continues,  or  until  the  physio- 
logic effects  (flushing  of  the  face  and  headache) 
are  evident.  When  this  fails  chloroform  by  inhala- 
tion or  a  hypodermic  of  morphia  may  be  given. 
In  the  intervals  between  the  attacks  the  prolonged 
use  of  the  iodide  of  potash  in  SO-grain  dose?  three 


NEUROSES  OF  THE  HEART.  143 

times  a  day  may  control  the  frequency  of  the  at- 
tacks by  influencing  the  associated  arterio-sclerosis, 
especially  if  there  is  a  history  of  syphilis. 

Habitual  exaltation  of  arterial  tension  is  influ- 
enced by  increasing  doses  of  nitro-glycerin  until  a 
dose  large  enough  to  produce  its  physiologic  action 
is  attained.  Sodium  nitrite  (dose  gr.  i-iii)  has  a 
similar  action.  In  pseudo-angina  the  causal  con- 
dition must  be  eliminated.  Static  electricity  has  a 
marked  psychic  action  in  cases  of  pseudo-angina. 
The  Schott  system  of  baths  and  exercises  improve 
the  condition  of  the  heart,  muscle  and  arteries  and 
should  be  employed  in  the  true  forms  of  angina. 
Erythrol-tetranitrate  in  grain  doses,  four  times 
in  the  24  hours,  is  a  new  remedy  for  the  relief 
of  the  anginal  attacks. 


CHAPTER  Til. 

AFFECTIONS   OF   THE  ARTERIES. 

Arteeial  Sclerosis  —  Aeterio-Scleeosis;  Ae- 
terio-capillary  fibrosis;   atheroma. 

pathology  axd  etiology. 
The  normal  activity  of  an  organ  is  dependent  on 
the  integrit}^  of  its  blood-vessels.  The  span  of 
life  is  determined  by  the  so-called  vital  rubber  of 
the  arterial  tissue,  and  justifies  the  oft  quoted 
axiom,  "A  man  is  only  as  old  as  his  arteries."  Kot 
long  ago  I  examined  a  youth  of  ten  who  was  prac- 
tically an  old  man  with  his  rigid  and  incom- 
pressible radials.  The  pathologic  process  of 
arterio-sclerosis  is  essentially  a  chronic  process 
leading  to  an  increase  of  arterial  connective  tissue 
involving  primarily  the  internal  coat  (intima)  fol- 
lowed by  calcareous  infiltration.  Sclerosis  of  the 
veins  (phlebo-selerosis)  may  be  primary  or  second- 
ary to  the  same  changes  in  the  arteries.  Arterio- 
sclerosis is  often  an  hereditary  affection  aided  by 
factors  which  result  in  the  misuse  of  arteries. 
Among  the  common  causes  are:  1,  Chronic  intox- 
ications: lead  poisoning,  syphilis,  alcoholism,  uric 
acid,  etc.,  which  by  augmenting  the  resistance  in 
the  peripheral  vessels,  raise  the  arterial  pressure. 


AFFECTION'S    OF    THE   ARTERIES.  145 

2.  Overeating  is  regarded  as  a  frequent  cause,  the 
excess  of  food  and  fluid  ingested  fill  the  blood 
vessels  to  repletion.  3.  Inordinate  muscular  work 
leads  to  peripheral  resistance  with  consequent  rise 
of  blood  pressure.  4.  Bright's  disease  may  lead 
to  primary  or  secondary  arterial  degeneration.  The 
causal  factors  predominating  in  males,  it  is  but 
natural  that  the  latter  are  the  chief  victims  to 
the  affection. 

SYMPTOMS. 

An  acute  arteritis  is  almost  never  of  clinical 
interest  although  some  clinicians  claim  to  make  a 
diagnosis  of  acute  aotitis  by  the  fixed  retro-steraal 
pain  associated  with  acute  disease  of  the  aortic 
valves.  Arterio-selerosis  is  frequently  a  post- 
mortem discovery.  The  diagnosis  rests  on  the 
general  manifestations,  but  more  often  on  symp- 
toms referred  to  special  organs,  the  arteries  of 
which  are  particularly  implicated  in  the  sclerotic 
process.  The  accessible  blood-vessels  are  hard  and 
incompressible.  The  sensation  is  often  that  per- 
ceived in  grasping  a  goose's  neck.  The  pulse  can- 
not be  obliterated.  The  pulse  may  be  of  high 
tension  yet  no  sclerosis  exists.  If  there  is  anv 
doubt,  palpate  the  pulse  with  two  fingers.  If  the 
artery  is  felt  beyond  the  point  of  compression  and 
is  easily  distinguished  from  the  other  tissues,  its 
walls  are  sclerosed. 

Next  to  increased  arterial  tension,  hypertrophy 


146  DISEASES   OF   THE    HEART. 

of  the  left  ventricle  is  the  most  frequent  symptom. 
Increased  arterial  tension,  palpable  arterial  in- 
duration and  hypertrophy  of  the  left  ventricle  are 
pathognomonic  of  the  disease.  There  are  distinct 
types  of  arterio-sclerosis:  1,  cardiac;  2,  cerebral; 
3,  renal;  and  4,  peripheral  types. 

Cardiac  sclerosis  of  the  coronary  arteries  may 
be  associated  with  varied  myocardial  lesions,  not- 
ably: fibroid  degeneration,  angina  pectoris,  heart 
aneurism,  etc.  The  hypertrophied  heart  so  com- 
mon in  arterio-sclerosis  may  eventuate  in  dilata- 
tion followed  by  the  usual  signs  of  cardiac  in- 
sufficiency (dyspnea,  dropsy,  etc.) 

Cerebral.  The  milder  symptoms  are  vertigo, 
cephalalgia,  tinnitus,  syncopal  attacks  and  tran- 
sient aphasia  and  paralysis.  Thrombosis,  cerebral 
embolism  and  the  formation  of  miliary  aneurisms 
followed  by  rupture  are  associated  lesions. 

Eenal.  The  symptoms  are  practically  those  of 
contracted  kidney,  viz.:  polyuria,  uremic  headaches 
and  vomiting.  In  the  peripheral  type,  tissue  star- 
vation leading  to  gangrene  may  ensue.  Implica- 
tion of  the  peripheral  arteries  in  the  scelrotic  pro- 
cess does  not  necessarily  imply  that  the  aorta  and 
its  branches  are  seriously  involved. 

Eecognition  of  increased  arterial  tension  is  often 
a  matter  of  education.  The  tonometer  of  Gaertner 
is  an  instrument  of  precision  in  gauging  blood- 
pressure.     The  blood-pressure  in  healthy  young 


AF&ECTIONS    OF   THE   ARTERIES. 


U1 


persons  is  from  100-130  millimeters  of  mercury. 
With  the  tonometer,  one  may  recognize  arterio- 


Fig.  13- 

a — Tonometer  provided  with  a  mercurial  gauge. 
b — Same   instrument   more   portable,   provided  with 
a  metal  gauge. 

sclerosis  without  palpable  changes  in  the  periph- 
eral vessels.     When   the   tonometric   figures   are 


148  DISEASES   OF  THE  HEART. 

low  with  clinical  evidence  of  arterio-sclerosis,  it 
is  a  sign  of  failing  heart  power. 

Anyone  mechanically  inclined  can  easily  con- 
struct a  tonometer  at  small  expense.  The  one  I 
have  used  for  some  time,  I  am  indebted  for  to  Dr. 
A.  W.  Perry  of  San  Francisco,  who  made  several 
for  his  medical  friends. 

TEEATMENT. 

The  causal  factors  must  be  considered.  A  his- 
tory of  syphilis  suggests  the  iodides,  which  may 
generally  be  recommended  as  routine  treatment. 
For  the  high  pulse  tension,  nitro-glycerin.  Vene- 
section is  indicated  in  instances  of  very  high  ten- 
sion associated  with  plethoric  symptoms.  Use  may 
also  be  made  of  the  Schott  methods. 

Aneukism  op  the  Thoeacic  Aoeta. 
etiology  and  pathology, 
The  etiology  is  concerned  with  the  same  factors 
predominant  in  arterio-sclerosis.  Alcohol,  syphilis 
and  overwork,  single  and  in  combination,  furnish 
the  impetus  for  arterial  changes  conducive  to 
aneurism.  The  different  varieties  of  aneurism  are 
of  greater  interest  to  the  pathologist  than  the 
clinician.  The  thoracic  portion  of  the  aorta,  ac- 
cording to  Lyman,  is  implicated  in  75  per  cent 
of  the  cases  of  aneurism.  Within  the  chest  nearly 
60  per  cent  of  the  cases  originate  in  the  ascending 


AFFECTIONS    OF   THE   ARTEPaES.  149 

portion  of  the  aorta,  while  nearly  30  per  cent  are 
seated  upon  the  arch  of  the  vessel. 

SYMPTOMS. 

Bramwell's  clinical  division  of  aneurism  is  a 
practical  one:  1.  Latent  aneurisms  which  give  no 
physical  signs.  2.  Those  presenting  signs  of  intra- 
thoracic pressure  but  in  which  it  is  difhcult  or  im- 
possible to  determine  the  nature  of  the  lesion  pro- 
ducing the  pressure.  3.  Aneurisms  with  marked 
pressure  symptoms  and  external  signs.  Our  pri- 
mary object  is  to  make  the  diagnosis  of  thoracic 
aneurism  and  later  to  define  its  site.  The  former 
object  is  attained  by  the  recognition  of  pressure 
symptoms  and  objective  signs. 

PEESSUEE  SIGNS. 

Pain  is  an  important  and  almost  constant  sign. 
When  dependent  on  pressure  or  stretching  of  the 
nerves,  it  is  sharp  and  lancinating  and  may  be 
paroxysmal  owing  to  alterations  in  the  intra- 
aneurismal  pressure.  When  due  to  pressure  against 
the  bony  structures,  it  is  a  continuous  gnawing  or 
boring  pain. 

Cough.  Usually  paroxysmal.  When  due  to 
pressure  on  the  recurrent  laryngeal  nerves  it  is  of 
a  brazen  ringing  character.  Pressure  on  the 
trachea  or  bronchus  may  also  provoke  a  cough. 

Dyspnea  owes  its  origin  to  one  of  the  following 
causes:     1,  Tracheal  compression;  2,  compression 


150  DISEASES   OF   THE   HEART. 

of  the  left  bronclius;  d,  pressure  on  the  recurrent 
laryngeal  nerves. 

Yenous  enlargement  of  the  veins  of  the  head  and 
arm  occurs  when  the  vena  cava  is  compressed. 

Edema  of  the  right  arm  occurs  when  the  sub- 
clavian vein  is  compressed.  Localized  edema  of 
the  chest  may  he  present. 

Aphonia  and  dyspnea  occur  when  the  right 
laryngeal  nerve  is  involved.  Pressure  of  the  left 
recurrent  laryngeal  causes  paralysis  of  the  cor- 
responding cord  with  aphonia.  Pressure  on  the 
sympathetic  nerve  causes  pupillary  contraction;  on 
the  thoracic  duct,  wasting,  on  the  esophagus,  dys- 
phagia, on  the  left  bronchus,  bronchiectasis  with, 
bronchorrhea. 

PHYSICAL    SIGNS. 

Inspection.  With  an  abnormal  pulsation,  a  tu- 
mor may  be  visible.  The  apex  beat  is  displaced 
from  pressure. 

Palpation.  In  deep-seated  aneurisms,  pulsation 
is  best  detected  by  bimanual  palpation,  one  hand 
over  the  spine  and  the  other  on  the  sternum,  at 
the  same  time  exerting  pressure  with  the  hand 
on  the  sternum.  In  addition  to  the  pulsation  one 
may  feel  the  diastolic  shock,  a  valuable  sign. 

Percussion  yields  the  most  reliable  evidence. 
Dullness  amounting  to  flatness  can  be  obtained 
over  a  superficial  aneurism,  the  area  of  dullness  de- 
pending of  course  on  the  situation  of  the  sac. 


AFFECTIONS   OF   THE   ARTERIES.  151 

Auscultation.  A  murmur  if  present  is  systolic 
in  time  with  maximum  intensity  over  the  area  of 
dullness  and,  transmitted  in  the  direction  of  the 
cervical  vessels  and  along  the  course  of  the  aorta; 
a  coexistent  diastolic  murmur  is  usually  associated 
with  aortic  insufHciency. 

In  the  peripheral  arteries  the  volume  of  the 
pulse  is  lessened.  The  pulse  in  the  two  radials 
may  show  differences  in  volume  and  time. 

Among  the  recent  signs  are  the  following:  1. 
Tracheal  tugging.  The  patient's  head  being  in- 
clined forward  to  relax  the  neck  and  the  cricoid 
cartilage  is  gi^asped  between  the  thumb  and  index 
finger,  the  trachea  at  the  same  time  drawn  upward, 
when,  if  aneurism  is  present,  a  pronounced  ascend- 
ing motion  will  be  felt  at  each  pulsation.  During 
the  maneuver,  breathing  must  be  suspended  and 
care  must  be  observed  to  avoid  mistaking  the  trans- 
mitted pulsations  in  the  cervical  vessels.  Ewart 
modifies  this  method  with  advantage.  The  ob- 
server stands  behind  the  patient  steadying  the 
latter's  head  against  his  body  and  grasping  the 
cricoid  cartilage  as  before.  In  health,  the  symp- 
tom is  only  slightly  present  if  at  all.  2.  Oblitera- 
tion of  the  pulse  in  the  abdominal  aorta  and  its 
branches.  When  this  sign  is  present,  the  aneur- 
ismal  sac  acts  as  a  reservoir  annihilating  the  ven- 
tricular systole  and  converting  the  intermittent 
into  a  gQjjti»iiQu§  stream  (Osier).    3.  Systolic  mw- 


153  DISEASES   OF   THE  HEART. 

rnur  heard  in  the  trachea  or  at  the  patient's  month 
when  opened  (Drummond).  4.  Tying  the  ex- 
tremities or  compressing  the  femorals  and  axillary 
arteries  will  intensify  the  pressure  symptoms.  5, 
Intra-thoracic  anscnltation.  An  esophageal  tube 
with  a  large  aperture  at  the  end  is  introduced  into 
the  esophagus  and  connected  with  a  stethoscope. 
Aneurismal  pulsation  and  murmur  are  heard 
(Eichardson).  6.  Systolic  pulsations  in  the  larynx 
and  trachea  are  heard  (Oliver).  7.  The  X-rays 
furnish  trustworthy  evidence.  I  have  frequently 
detected  thoracic  aneurisms  by  their  aid  when  no 
sign  was  present.  Of  course  errors  are  as  frequent 
by  this  as  by  other  methods,  but  a  thorough  mas- 
tery of  chest  radioscopy  is  the  only  reliable  means 
of  eliminating  mistakes. 

LOCATING  THE   SITE  OE  AN  ANEUEISM. 

Ascending  aorta.  Pressure  symptoms  evident  by 
distension  of  the  veins  of  the  neck,  head  and  arms. 
Displacement  of  the  heart  outward,  forward  and 
upward.  Appearance  of  tumor  and  dullness  to 
the  right  of  the  sternum  in  the  upper  second  or 
third  intercostal  spaces. 

Transverse  portion.  Intense  pressure  symptoms 
owing  to  the  relatively  shorter  antero -posterior 
diameter  of  the  chest  at  this  point.  The  tumor 
may  appear  in  the  Jugular  fossa.  Area  of  dullness 
over  the  manubrium  or  along  the  left  sternal  bor- 
der. 


AFFECTIONS   OF   THE  ARTERIES.  153 

Descending  portion.  Pressure  signs  are  slight. 
Evidence  of  vertebral  compression  with  intense 
pain.  Dullness,  if  present,  appears  at  a  point  on 
the  left  side  of  the  spine  at  about  the  eighth  dorsal 
vertebra. 

Prognosis.  Usually  fatal.  Spontaneous  cure, 
rare.    Death  from  pressure  symptoms  or  rupture. 

DIAGNOSIS. 

From  pulsation  of  the  aorta  seen  in  aortic  re- 
gurgitation; often  difficult.  In  such  instances 
defer  diagnosis  until  tumor  is  unmistakable. 
Aortic  pulsations  in  neurotic  subjects:  ISTegative 
signs  of  aneurism.  Pulsating  empyema:  In  this 
affection,  throbbing  is  diffuse,  moving  the  entire 
side;  pulsation  not  expansile;  absence  of  mur- 
mur and  diastolic  shock;  hypodermic  needle 
shows  pus.  Solid  tumors:  Pressure  phenomena 
less  marked;  if  tumor  shows  pulsation  it  is  not 
expansile  nor  attended  by  the  auscultatory  signs 
of  aneurism;  tracheal  tugging  is  absent. 

TREATMENT. 

Eest  and  a  restricted  diet.  A  low  diet  such  as 
suggested  by  Tufnell  reduces  intra-aneurismal 
pressure  and  favors  coagulation.  Potassium  iodide 
(10  to  20  grains,  3  times  a  day)  is  of  undoubted 
value.  Venesection  often  gives  relief  to  pressure 
symptoms.  Insertion  of  wire  into  the  sac  with 
the  use  of  electrolysis  according  to  the  Loreta 
method  has  given  me  good  results  in  two  cases. 


154  DISEASES   OF  THE  HEART. 

My  colleagues  Kerr  and  Eosenstim  of  this  city 
hare  also  reported  cures.  Thome  and  others  have 
reported  much  improvement  following  the  use  of 
baths  on  the  Schott  principle. 

A  method  of  recent  introduction  and  worthy  of 
some  consideration  is  the  use  of  gelatin  injections. 
In  1895,  Dastre  demonstrated  that  if  a  solution 
of  gelatin  is  injected  into  the  veins  of  a  dog,  it 
made  the  blood  more  coagulable.  The  solution 
for  injection  consists  of  a  1  per  cent  sterilized 
solution  of  gelatin  in  a  0.1  per  cent  solution  of 
sodium  chloride.  Of  this  solution,  from  2-5  ounces 
is  injected  every  third  or  fifth  day,  according  to 
the  reaction,  into  the  sub-cutaneous  tissues.  No 
danger  attends  this  treatment  beyond  the  possi- 
bility that  a  clot  may  be  carried  into  the  general 
circulation.  The  solution  for  injection  is  placed 
in  a  flask,  which  is  sealed  and  then  sterilized. 
When  ready  some  of  the  solution  is  introduced  into 
a  flask  fitted  with  a  cork  and  two  tubes  like  a  wash- 
bottle.  To  the  long  tube  a  sterilized  needle  is 
attached  and  to  the  short  tube,  a  rubber  air  ball. 
The  flask  is  introduced  into  a  water  bath  to  liquefy 
the  gelatin  and  while  kept  there,  the  injection  is 
begun. 

The  calcium  salts  have  recently  been  recom- 
mended. Marked  improvement  in  one  of  Cohen's 
cases  followed  the  use  of  hydrated  calcium  chloride 
in  doses  of  J  dnm  claily. 


CHAPTER  VIII. 

ADDENDUM. 

The  Heaet  Eeflex. 

Three  years  ago  attention  was  directed  to  an 
heretofore  undescribed  clinical  phenomenon  which 
I  called  the  heart  reflex.  It  is  practically  a  myocar- 
dial contraction  consequent  on  irritation  of  the 
skin  of  the  precordia  hy  vigorous  rubbing  with 
the  finger  or  better  still  by  a  spray  of  ether  and 
is  manifest  by  the  Roentgen  rays  and  the  liuoro- 
scope.  It  can  be  most  easily  provoked  in  children. 
The  contraction  of  the  myocardium  is  of  sudden 
and  momentary  duration  and^  like  other  reflex  acts, 
soon  becomes  exhausted.  My  assistant,  Dr.  Louis 
Gross,  and  myself  saw  both  ventricles  recede  fully 
1^  inches  on  either  side  after  directing  a  spray  of 
ether  on  the  precordia  in  an  emaciated  girl  of  14 
years.  Of  course  the  anatomic  heart  in  the  adult 
measures  only  3^  inches  in  breadth,  but  we  are 
here  concerned  with  the  physiologic  heart. 

To  properly  appreciate  the  phenomenon  of  the 
heart  reflex  for  therapeutic  and  diagnostic  pur- 
poses, attention  must  be  directed  to  the  lung  re- 
flex.*   If  the  skin  of  the  thorax  is  irritated,  arti- 

*New  York  Medical  Journal,  Jan.  13,  1900, 


156  DISEASES   OF   THE   HEART. 

ficial  lung  dilatation  ensues.  The  degree  of  dila- 
tation varies  witli  the  severity  and  extent  of  cu- 
taneous irritation.  Vigorous  rubbing  of  the  skin 
of  the  precordia  is  sufficient  to  obliterate  the  area 
of  superficial  cardiac  dullness^  if  irritation  is  made 
over  the  lower  lung  border,  percussion  will  show  in 
the  axillary  line  a  descent  of  the  lower  lung  border 
fully  6  cm.,  a  degree  of  dislocation  even  exceeding 
that  obtained  by  forced  inspiration.  Aside  from 
its  percussional  recognition,  the  appearance  of 
the  reflex  by  means  of  the  Eoentgen  rays  is  dis- 
tinctive. Coincident  with  the  discharge  of  the 
reflex,  the  lung  area  implicated  shows  increased 
brightness  lasting  from  a  few  seconds  to  four  min- 
utes, the  lung  after  that  time  assuming  the  normal 
skiascopic  appearance. 

In  a  recent  contribution,*  I  espoused  the  theory 
that  the  real  factor  involved  in  balneo-  and 
mechano-therapeutics  (Schott  treatment)  was  de- 
pendent on  cutaneous  irritation  provoked  by  exer- 
cise and  baths.  In  accordance  with  this  theory,  I 
have  since  this  contribution  employed  vigorous 
cutaneous  friction  by  means  of  a  rough  towel  after 
immersion  of  the  patients  in  a  warm  bath  (15  min- 
utes duration)  in  cases  of  chronic  heart  disease 
with  results  emulating  the  conventional  Schott 
method.  By  my  simple  and  expeditious  method, 
relief  of  dyspnea  follows,  there  is  reduction  in 

*The  Medical  News,  Jan.  7,  1899. 


ADDENDUM. 


157 


cardiac  Toliime  and  a  marked  reduction  in  pulse 
rate  with  increase  in  volume  and  force.  The  ac- 
companying illustration  is  a  rough  reproduction 
obtained  in  a  young  man  \rith  a  massive  dilatation 
of  both  ventricles;  a,  represents  the  percussional 
area  of  the  heart.     The  dark  area  represents  the 


Fig.  14— Illustration   of   Heart   Reflex. 

a — Percussional  area  of  dilated  heart. 

b — Area  after  application  of  cutaneous  irritation. 

area  of  cardiac  dullness  after  directing  a  spray  of 
ether  on  the  skin  of  the  precordia  and  is  caused 
not  vrholly  by  a  reduction  in  cardiac  volume  but 
by  the  lung  reflex  which  induces  the  dilated  lung 
to  encroach  on  the  area  of  cardiac  dullness.    After 


158  DISEASES   OF   THE   HEART. 

waiting  ten  minutes,  a  time  exceeding  that  neces- 
sary for  the  lung  to  recede,  the  percussion  area,  b, 
is  obtained,  which  actually  represents  the  decrease 
in  the  area  of  the  heart.  Like  results  follow  treat- 
ment by  cutaneous  irritation. 

This  illustration  will  serve  to  exemplify  the  aid 
which  this  phenomenon  furnishes  in  the  differen- 
tial diagnosis  of  a  pericardial  exudate  from  a  dila- 
tation of  the  heart,  and  I  regard  this  heart  reflex 
test  as  pathognomonic  and  far  exceeding  all  other 
methods  yet  recommended  in  differentiation.  One 
of  the  most  difficult  problems  for  the  clinician  is  to 
distinguish  between  a  dilatation  of  the  heart  and 
pericardial  effusion.  If  in  a  given  case  of  increased 
cardiac  dullness  which  has  been  carefully  outlined, 
we  direct  a  spray  of  ether  on  the  skin  of  the  pre- 
cordiaand  note  after  four  minutes  (the  time  nec- 
essary for  the  lung  reflex  to  be  abolished)  a  reduc- 
tion in  the  area  of  cardiac  dullness  however  slight, 
we  are  justified  in  concluding  that  we  are  dealing 
with  cardiac  dilatation  and  not  with  a  pericardial 
effusion.  The  heart  reflex  is  also  a  valuable  index 
to  the  state  of  the  myocardium. 

Eelation  of  Diseases  op  the  Heaet  to  Othek 
Diseases. 
Abdominal  Typhus. — Myocarditis  is  often  re- 
sponsible for  sudden  circulatory  collapse.     Pulse 
rate  not  in  proportion  to  temperature.     Average 


ADDENDUM.  159 

rate,  84-110  per  minute.  Pulse  of  more  than 
130  for  some  days  is  an  ominous  sign.  Pulse 
dicrotism^  characteristic  but  not  pathognomonic. 
During  convalescence  a  sub-normal  pulse  rate  is 
frequent.  Venous  thrombosis  occurs  in  one  per 
cent  of  all  cases  (Murchison).  It  is  the  result 
of  cardiac  failure  and  implicates  most  frequently 
the  femoral  veins.  Peri  and  less  often  endocarditis 
are  complications. 

Anemia  (perxicious). — Hemic  murmurs  con- 
stant. Visible  arterial  pulsations.  Pulse  full  and 
suggests  the  vater-hammer  beat  of  aortic  regurgi- 
tation. Capillary  pulse  often  seen.  Superficial 
veins  prominent  and  may  pulsate. 

Beight's  Disease. — Anemia  an  early  symptom. 
In  the  chronic  forms,  pulse  tension  increased  and 
arterial  wall  thickened.  Persistent  high  tension 
is  one  of  the  earliest  and  most  important  symptoms 
of  interstitial  nephritis  (Osier).  Hypertrophy  of 
the  left  ventricle  common. 

Chloeosis. — Palpitation  of  the  heart.  Increase 
in  the  area  of  cardiac  dullness.  Systolic  murmur 
heard  in  second  left  interspace,  accompanied  some- 
times by  a  pulsation,  and  is  produced  at  mitral 
orifice  by  relative  insufficiency  of  the  valves  ac- 
companying dilated  ventricles  (Balfour).  Over 
right  jugular  vein,  a  continuous  murmur  (bruit  de 
diable  or  humming-top  murmur).  Pulsation  in 
peripheral  veins  and  a  tendency  to  thrombosis, 


160  DISEASES   OF   THE   HEART. 

usually  in  the  femoral,  occasionally  in  the  longi- 
tudinal sinus. 

Choeea. — The  theory  is  gaining  ground  that 
chorea  is  a  rheumatic  manifestation.  Pericarditis 
and  endocarditis  frequent  complications,  the  lat- 
ter occurring  in  about  one-half  of  all  cases  (Osier). 
The  murmurs  may  also  he  due  to  anemia.  Osier 
examined  140  persons  having  suffered  at  least  two 
years  previously  from  chorea.  In  51,  heart  nor- 
mal; in  72,  signs  of  organic  lesion;  in  17,  cardiac 
disturbances. 

Diabetes. — Plasma  of  blood  is  loaded  with  fat 
(lipemia)  which  form  fat  emboli  in  lung  capillaries. 
Heart  changes  not  characteristic  and  endocarditis 
is  infrequent.  Nutritional  disturbances  cause  ar- 
terio  sclerosis. 

DiPHTHEEiA. — Myocarditis  and  degeneration 
and  endo  and  pericarditis  may  occur.  Cyanosis 
and  heart  failure  may  be  sudden.  Myocarditis  as 
a  post-diphtheritic  manifestation.  Sudden  death 
often  caused  by  changes  in  vagus  or  its  cardiac 
branches  (neuritis)  and  may  be  a  sequel  of  the 
mildest  cases. 

Dyspepsia. — Flatulency  may  cause  mechanic 
disturbance,  viz.,  cardiac  dyspnea  or  pseudo-anginal 
attacks.  The  pulse  will  be  found  weak  and  heart 
tones  enfeebled.  The  left  inter-scapular  sign  is 
present  (Abrams).    Heart  neuroses  frequently  owe 


ADDENDUM.  161 

their  genesis  to  the  absorption  of  the  products  of 
indigestion. 

Emphysema. — In  no  other  affection  other  than 
in  congenital  heart  disease  is  cyanosis  so  marked 
and  this,  with  comparative  comfort  of  the  patient. 
Dilatation  and  hypertrophy  of  right  ventricle; 
later,  hypertrophy  is  general. 

Exophthalmic  Goitre. — Cardio-vascnlar  dis- 
turbances occur  early.  Heart  sound  intense  and 
may  be  heard  as  far  as  four  feet  from  patient 
(Graves).  Throbbing  of  carotids  and  abdominal 
aorta.  Hypertrophy  of  heart  and  murmurs  at 
base. 

Gout. — Arterio-sclerosis,  common.  Blood  ten- 
sion persistently  high  leading  to  ventricular  hyper- 
trophy, rupture  of  vessels  (apoplexy)  and  aneurism. 

Grippe. — In  the  "influenza  heart"  cardiac  weak- 
ness is  very  alarming  and  out  of  proportion  to  the 
height  of  the  fever.  Pulse  feeble  and  intermittent 
and  may  persist  after  convalescence. 

Hysteria. — Increased  heart  rapidity  on  slight- 
est emotion.  Pain  in  precardia  may  simulate  an- 
gina. Stigmata  or  hemorrhages  in  the  skin  and 
flushes  are  vaso-motor  phenomena. 

Icterus, — Slow  pulse  (30  or  even  20)  common. 
Ecchymoses  in  severe  forms. 

Insanity. — Mental  symptoms  often  associated 
with  heart  disease.  Delirium,  hallucinations  and 
morbid  impulses  (suicide)  frequently  terminate  the 


162  DISEASES   OF  THE  HEART. 

close  of  the  disease.  Insanity  may  develop  in 
aortic  and  mitral  disease  in  the  stage  of  compensa- 
tion. 

Makasmus. — ^In  the  terminal  stages  of  chronic 
diseases,  thrombosis  may  occur  in  the  sinuses 
(marantic  thrombus). 

Neueasthenia.  —  Cardio-vascular  symptoms 
often  predominate.  Palpitation,  irregular  and 
rapid  action  of  the  heart  with  cardiac  pains. 
Slightest  emotional  disturbances  excites  heart  and 
it  is  difficult  to  dissuade  neurasthenics  that  there 
is  no  organic  lesion.  A  throbbing  aorta  is  a 
prominent  symptom  and  is  so  pronounced  as  to 
suggest  aneurism.  Flushes  of  heat  and  hyperemia 
of  skin  common  as  vaso-motor  phenomena. 

Phthisis. — False  or  cardio-pulmonary  murmurs 
result  from  the  contraction  of  a  lung  cavity  caus- 
ing heart  dislocation.  The  indurated  lung  inten- 
sifies the  murmur.  A  systolic  murmur  at  the  apex 
may  simulate  mitral  regurgitation.  The  murmur 
is  usually  caused  by  the  impact  of  the  heart  upon 
partially  consolidated  lung  tissue  driving  out  the 
air.  A  murmur  of  this  kind  is  superficial,  most 
distinct  during  expiration  and  is  inaudible  when 
the  patient  lies  down.  In  neurotic  phthisical  per- 
sons a  false  systolic  murmur  is  heard  at  the  apex 
when  the  heart  action  is  excited.  Chronic  valTular 
cases,  the  mitral  being  most  frequently  involved 
(17  times  in  20  cases).    Congenital  stenosis  of  pul- 


ADDENDUM.  163 

monary  orifice  is  frequently  associated  mth  this 
disease. 

Pleueist. — With,  effusion  either  dislocates  the 
apex  or  the  whole  heart.  There  is  no  twisting  of 
the  heart  but  a  dislocation  of  the  mediastinum 
which,  carries  the  heart  with  it. 

PxEUiioxiA  (cEOUPOUs). — Average  pulse  rate, 
100-110.  Heart  failure  is  manifested  by  increased 
frequency  (120  or  more).  Failure  of  right  beart- 
chamber  is  indicated  by  dilatation  of  this  ventricle, 
viz.:  increased  dullness  to  the  right,  epigastric  pul- 
sation, systolic  murmur,  fetal  heart  sounds,  espe- 
cially second  pulmonic  sound  and  venous  stasis. 
It  is  the  right  ventricle  which  needs  watching  and 
any  evidence  to  be  gained  is  derived  by  frequent 
auscultation  of  the  pulmonic  tones  and  not  by 
palpitation  of  radial  pulse. 

PiHEU^iATiSii. — Endocarditis  is  the  most  fre- 
quent complication,  and  the  mitral  segments  are 
most  frequently  involved.  Pericarditis  is  espe- 
cially frequent  in  children,  and  is  attended  by  a 
peculiar  delirium.  ^Myocarditis  is  commonly  as- 
sociated with  endo-pericardial  changes. 

Spixal  Cuea'atuee. — Curvatures  of  the  spine 
result  in  circulatory  and  respiratory  disturbances. 
The  heart  of  hunchbacks  is  usually  increased  in 
size  and  the  right  heart  is  generally  dilated,  re- 
sulting in  disturbances  in  the  pulmonic  circula- 
tion. 


164  DISEASES   OF  THE   HEART. 

Syphilis. — In  the  heart,  gummata  frequently 
involve  the  left  ventricular  wall  and  are  usually 
encysted.  A  fibro-sclerotic  myocarditis  may  cause 
sudden  death.  Syphilitic  endocarditis  is  not  in- 
frequent. Arterial  syphilis  may  occur  as  an  oblit- 
erating endarteritis  or  as  a  gummatous  periarteritis 
implicating  the  coronary,  cerebral  and  other 
arteries. 

The  Ueic  Acid  Diathesis  has,  of  late,  assumed 
an  important  position  in  clinical  medicine.  Pal- 
pitation of  the  heart  is  frequent,  particularly  after 
eating,  and  increased  arterial  tension  is  an  early 
and  prominent  symptom.  Its  occurrence  during 
an  uric  acid  storm  is  pathognomonic  and  this  fact 
I  have  learned  to  appreciate  since  using  the  tono- 
meter. Circulating  uric  acid  produces  universal 
arterio-spasm  followed  sooner  or  later  by  the  well- 
known  symptomatic  complex — arterio-sclerosis, 
gout  and  contracted  kidney. 

Clinical  Memoeanda  of  the  Cakdio-Vasculab 

System. 

the   pulse. 

1.  The  number  of  pulse  and  heart  beats  in  a 
normal  adult  is  71-72  per  minute. 

2.  The  pulse  frequency  in  different  ages  in  the 
male:  0-136;  5-88;  10-15,  78;  15-20,  69.5;  20-25, 
69.7;  25-30,  71;  30-50,  70.    (Quetelet.) 


ADDENDUM.  165 

3.  In  the  female,  the  pulse  frequency  is  greater 
by  from  1  to  4.5  beats  a  minute. 

4.  Influence  of  position  on  pulse:  In  sitting 
posture,  5  beats  more  a  minute  than  in  recumbent 
position;  standing,  9  beats  more  than  while  sitting 
and  14  more  beats  than  in  recumbent  posture. 

5.  Influence  of  activity:  Slight  activity  in- 
creases beats  10-20  and  running  may  increase  the 
beats  to  140  and  this  increase  may  last  from  ^-1 
hour. 

6.  Influence  of  food:  After  dinner  the  average 
increase  is  16. 

7.  Influence  of  the  barometer:  A  barometric 
rise  of  1^  cm.  increases  the  pulse  frequency  1.3  per 
minute  (Yierordt). 

8.  In  sleep  the  pulse  is  slower,  especially  in 
children. 

9.  In  fever  the  pulse  rises  synchronously  with 
the  temperature  and  averages  an  increase  of  10 
beats  for  every  degree  above  98  deg.  F.  Expressed 
according  to  centigrade:  P=80-f-8  (T — 37). 

10.  Eelation  in  time  of  heart  tone  and  radial 
pulse  beats  in  seconds:  Eadial  pulse,  0.224  later 
than  the  first  cardiac  tone.  The  left  is  felt  0.01- 
0.03  of  a  second  later  than  the  right  radial  pulse. 

11.  Eelation  of  respiration  and  pulse:  1:3^-4. 
It  takes  four  times  as  long  for  the  blood  to  go 
through  the  systemic  as  through  the  pulmonic  cir- 
culation. 


166  DISEASES   OF   THE   HEART. 

THE  HEAET. 

1.  The  work  of  the  right  ventricle  is  one-eighth 
that  of  the  left. 

2.  The  intensity  of  the  heart  tones  is  as  follows, 
beginning  with  the  loudest:  1,  systolic  mitral;  2, 
systolic  tricuspid;  3,  second  pulmonic  tone;  4, 
second  aortic;  5,  second  mitral;  6,  second  tricuspid; 
7,  systolic  pulmonic;  8,  systolic  aortic  tone. 

2.  Relative  intensity  of  second  sounds  at  base. 
Second  pulmonic  sound  invariably  accentuated  in 
young  children  and  frequent  in  youth.  After  the 
fortieth  year  it  is  rare  to  find  a  pulmonic  second 
sound  as  loud  as  the  corresponding  second  aortic 
sound.  Between  20  and  30  there  is  no  marked 
accentuation  of  either  sound  (Creighton). 

3.  In  embolism  from  endocarditis  of  left  heart 
the  organs  are  affected  in  the  following  propor- 
tions: Kidney,  57  times;  spleen,  39  times;  brain, 
15;  skin,  14,  and  liver  and  intestines,  1  time 
(Sperling). 

4.  Location  of  endocarditis  in  300  cases:  Mitral 
valve,  255  times;  aortic  valve,  129  times;  tricuspid 
valves,  29  times;  pulmonary  valve,  3  times  (Sper- 
ling). 

5.  Endocarditis  in  the  sexes:  In  238  cases,  86 
males,  152  females  (Willigk);  in  230  cases,  118 
males,  112  females  (Bamberger). 

6.  Influence  of  pregnancy  on  heart  affections 
from  84  observations  by  Porak:     Condition  sta- 


ADDENDUM.  167 

tionary  in  25%  of  the  cases,  temporary  aggrava- 
tion in  4.76%,  persistent  aggravation,  60.71%; 
improvement  during  cMld-lDed,  26.19%;  cardiac 
symptoms  aggravated  by  labor,  13.09%.  Death, 
occurred  before  delivery,  5  times;  during  delivery, 
2  times;  during  child-bed,  25  times;  after  tem- 
porary improvement,  8  times.  The  foregoing 
table  refers  to  pronounced  cardiac  lesions. 

7.  Insanity  and  heart  disease:  Among  68  cases 
of  melancholia,  11  cases  of  heart  disease  (Esquirol); 
among  100  insane,  31  cases  (Calmeil);  602  insane, 
75  cases  (Vienna  asylum). 

CHILDKEN. 

1.  The  movements  of  the  heart  begin  one- 
eighth  of  a  minute  after  birth. 

2.  The  normal  apex  beat  is  usually  in  the  fourth 
interspace  just  outside  the  mammary  line.  This 
position  has  been  attributed  to  the  greater  relative 
narrowness  of  the  infant's  chest  in  the  transverse 
diameter  and  the  relatively  larger  heart.  The 
than  in  the  adult.  Symington  contends  in  opposi- 
tion to  the  current  belief  that  the  position  of  the 
heart  and  great  vessels  is  the  same  as  in  the  adult. 

3.  Functional  disorders:  Up  to  the  seventh  year 
cardiac  action  during  sleep  is  often  of  unequal 
strength  and  rhythm  and  prone  to  be  irregular  in 
the  healthiest  children  during  sleep  and  greatly 
influenced  by  breathing  (Da  Costa).    Irregularity 


168  DISEASES   OF   THE   HEART. 

durinsr  wakino;  hours  indicates  cardiac  disorder  un- 
less  there  are  evidences  of  meningeal  disease 
(Smith). 

4.  Bulging  of  precardia  more  frequent  in  car- 
diac diseases  of  children  owing  to  flexibility  of 
thorax. 

5.  Aneurisms  under  the  age  of  20,  if  not  trau- 
matic in  origin  are  caused  by  embolism  from  a  pre- 
existing endocarditis.  The  cerebral  arteries  are 
most  frequently  involved. 

6.  The  ductus  arteriosus  is  not  obliterated  as  a 
rule  until  two  weeks  after  birth.  Persistence  of 
the  same  after  the  first  month  is  pathologic. 

7.  Most  frequent  congenital  lesion  is  stenosis  of 
the  pulmonary  artery. 

8.  The  most  common  evidence  of  a  congenital 
heart  lesion  is  cyanosis.  It  affects  more  male  in- 
fants— 180  cases,  two-thirds  males  (Aberle). 
Cyanosis  does  not  always  commence  at  birth  and 
may  be  retarded  in  appearance  for  years.  Club- 
bing of  the  fingers  and  toes  and  a  pigeon-chest 
are  two  common  abnormalities  in  cyanosis.  Other 
general  conditions  are  lack  of  heat  and  retarded 
development. 

9.  Prognosis  in  cyanosis:  Thirty-five  per  cent 
die  before  the  end  of  the  first  year;  more  than  two- 
thirds  die  before  the  age  of  eleven  years,  and  only 
five  lived  more  than  45  years  (in  159  cases  col- 
lected by  Aberle).     The  most  frequent  modes  of 


ADDENDUM.  169 

death  are  conralsions,  dyspnea,  lieiiiorrhage,  coma 
and  phtliisis. 

10.  Most  frequent  lesions  in  cyanosis:  Stenosis 
of  pulmonary  artery,  transposed  aorta  and  pul- 
monary arter}',  one  auricle  and  one  ventricle,  right 
ventricle  divided  into  t"wo  cavities  by  a  super- 
numerary septum.  In  more  than  half  the  cases 
the  lesion  is  located  in  the  pulmonary  artery. 


STETHOPHOXOMETRY. 

Since  reference  yvas  made,  on  page  55,  to  meth- 
ods of  measuring  the  intensity  of  the  heart  tones, 
I  have  had  constructed  for  me,  after  considerable 
experimentation,  a  simple  stethophonometer, 
which  can  be  readily  attached  to  any  stethoscope.* 


STETHOPHONOMETER. 


The  stethophonometric  attachment  weighs  about 
two  ounces  and  is  based  on  the  principle  of  a  disc 
valve  with  attachment  on  one  side  for  the  stetho- 
scope and  on  the  other  side  for  the  bell.     The 


*  Made  by  the  Shoenberg  Electrical  Co.,  E.  Spreck- 
els  Building,  San  Francisco. 


170  DISEASES   OF   THE   HEART. 

object  of  tlie  valve  is  to  offer  resistance  to  tlie 
sound  waves.  There  are  three  hard  rubber  discs, 
all  of  which  are  perforated.  The  center  disc  is 
easily  movable  by  means  of  a  handle  so  as  to  carry 
the  opening  away  from  the  other  two  discs.  On 
the  face  of  one  of  the  discs  is  a  graduated  scale, 
which  enables  one  to  measure  the  intensity  of  the 


STETHOPHONOMETRIC   ATTACHMENT. 

cardiac  tones.  If  the  heart  sounds  are  loud  enough 
to  overcome  the  resistance  of  the  valves,  further 
resistance  may  be  offered  by  the  insertion  of  a 
small  rubber  cork  in  the  bore  of  the  plug  which 
fits  into  the  stethoscope.  It  will  rarely  be  found 
necessary  to  make  use  of  the  latter  expedient. 


INDEX. 


Anemia     (Pernicious)     in 
relation  to  Heart  Dis- 
ease, 159 
Anemia,  Pulmonary,  46 
Anemic  Murmurs,  45 
Aneurism,    Locating    Site 

of,  152 
Aneurism      of      Thoracic 
Aorta,  148 

etiology  of,  148 

diagnosis  of,  153 

pathology  of,  148 

symptoms  of,  149 

treatment  of,   153 
Angina  Pectoris,  137 

etiology  of,  138 

pathology  of,  138 

symptoms  of,  138 

treatment  of,  142 
Angina,  Pseudo,  140 
Aorta,  Aneurism  of  Thor- 
acic, 148 
Aortic   Regurgitation,    34, 
114 

pulse  in,  54 
Aortic  Stenosis,  34,  116 

pulse  in,  54 
Apex  beat,  30 

location  of,  31 

in  hypertrophy,  50 

in  dilatation,  51 
Aphasia,   Temporary,   21 


Arrythmia,  66,   136 

etiology  of,  137 

significance  of,  137 
Arterial  Sclerosis,  144 
Arterial     wall,     condition 

of,  51 
Arteries 

condition  of  wall  of,  51 

atheroma  of,  51 
Arteries,     Affections     of, 
144 

atheroma,  144 

aneurism      of      thoracic 
aorta,  148 
Asthma,  Bronchial,   19 

from  cardiac  asthma,  19 
Asthma,  Cardiac,  18 

from  bronchial  asthma, 
19 
Asthma  Dyspepticum,  16 
Atheroma,  51,  144 

etiology  of,  144 

pathology  of,  144 

symptoms  of,  145 

treatment  of,  148 
Bamburger  Sign,  99 
Baths,   Saline,  76 
Blood  vessels,  13 
Brachycardia,  54,  113 

symptoms  of,  135 

treatment  of,  135 


TI. 

INDEX. 

Breast  Pang,  J37 

Diphtheria   in  relation 

to 

Bright's  Disease 

Heart  Disease,  160 

in     relation     to 

Heart 

Dropsy,  Treatment  of, 

85 

Disease,  159 

Dropsy,  Cardiac,  cause 

of, 

Cardiac  Cachexia, 

12 

12 

Cardiodynia,  137 

Dropsy     of     Pericardium, 

Cardio-respiratory 

mur- 

107 

murs,  45 

Dyspepsia   in   relation 

to 

Children,  Heart  in, 

167 

Heart  Disease,  160 

Chlorosis 

Dyspnea,  13 

in     relation     to 

Heart 

Treatment  of,  85 

Disease,  159 

Dyspnea,    Gastrectatic, 

14 

Chorea 

course  of,  14 

in     relation     to     Heart 
Disease,  160 
Compensation,  11 
Treatment  during  stage 
of,  68 
Compensation,  Failure  of, 
II 
Dilated  Heart  as  cause 

of,  50 
Treatment  during  stage 
of,  70 
Corrigan's  Pulse,  54 
Cough,   Treatment   of,   89 
Cyanosis,  12 

Degeneration,   Fatty,   126 
Diabetes 

in     relation     to     Heart 
Disease,  160 
Digestive  Apparatus,  19 
Dilatation  of  Heart,  50 
apex  beat  in,  51 
symptoms  of,  50 


with  angina  pectoris,  15 
Edema  of  the  Lungs,  14 
Emboli,  13 
Emphysema  in  relation  to 

Heart  Disease,  161 
Endocarditis,  22,  109 
chorea  as  cause  of,  22 
forms  of,  24 
chronic,  24,  no 
Gonorrheal,  109 
Malignant,  24,  no 
Simple,  24,  no 
Ulcerative,  no 
Valvular,  23 
results  of,  25 
Exophthalmic    Goitre    in 
relation   to    Heart   Dis- 
ease, 161 
Exercise   in   treatment   of 

heart  disease,  83 
Fatty      Degeneration      of 
Heart,  126 


INDEX. 


III. 


Fatty  Heart,  126 

Fatty  Overgrowth,   127 

Fatty  Overgrowth,  127 

Heart    Strain    as    cause 

Fibrosis,    Arterio-Capil- 

of,  25 

lary,  144 

Hypertrophy  of,   25,   49 

Gastrectatic  Dyspnea,   14 

in   febrile  affections,  21 

cause  of,  14 

in  pregnancy,  22 

with  angina  pectoris,  15 

in  relation  to  other  dis- 

Gastric Complications 

eases,  21,  158 

Treatment  of  90 

Mitral    Regurgitation, 

Glottis,  Edema  of,  14 

36,  117 
Mitral  Stenosis,   12,  36, 

Gout  in  relation  to  Heart 

Disease,  161 

118 

Grippe  in  relation  to  Heart 

Myocarditis,  125 

Disease,  161 

Prevention  in,  65 

Heart,    166 

Prognosis  of,  27 

clinical   memoranda   of, 
166 

Pulmonary      Regurgita- 

Dilatation, 50 

tion,  121 
Pulmonary  Stenosis, 

Endocarditis,   23,    109 

121 

Hypertrophy  of,  49 

Pulse  in,  51 

in  children,  167 

Treatment  of,  65 

inhibition  of,  59 

Tricuspid  Regurgita- 

Neuroses of,  128 

tion,  120 

Tones  of,  55 

Tricuspid   Stenosis,    121 

Heart,  Diseases  of,  21 

Heart    Diseases,    iu    rela- 

Aortic   Regurgitation, 

tion  to,  158 

34,  114 

Abdominal  Typhus,  158 

Aortic  Stenosis,  34,  116 

Anemia   (Pernicious), 

Congenital,  124 

159 

Diagnosis   of,    30 

Bright's  Disease,  159 

X-Ray  in,  63 

Chlorosis,  159 

Dilatation  of,  25 

Chorea,  160 

Endocarditis,  22,  109 

Diabetes,    160 

Etiology  of,  23 

Diphtheria,    160 

Fatty  Degeneration,  126 

Dyspepsia,  160 

Fatty  Heart,  126 

Emphysema,  161 

IV. 


INDEX. 


Exophthalmic    Goitre, 
i6i 

Gout,  i6i 

Grippe,  i6i 

Hysteria,  i6i 

Icterus,  i6i 

Insanity,  i6i 

Marasmus,  162 

Neurasthenia,  162 

Phthisis,   162 

Pleurisy,  163 

Pneumonia    (Croup- 
ous), 163 

Rheumatism,  163 

Spinal  Curvature,  163 

Syphilis,  164 

Uric-Acid  Diathesis, 
164 
Heart,  Irregular  (Arryth- 

mia),  136 
Heart,    Rapid    (Tachycar- 
dia), 132 
Heart  Reflex,  155 
Heart    Stout    (Brachycar- 

dia),  134 
Heart  Strain,  25 
Heart  Tones 

Aortic,  58 

Intensity  of,  55 

Mitral,  58 

Pulmonic,  58 

Tricuspid,  58 
Heart  Tonics,  71 

Table  of,   77 
Hemic  Murmurs,  46 


Hemopericardium,    107 

causes  of,  107 

treatment  of,   108 
Hemoptysis,  14 

Treatment  of,  89 
Hemorrhages,    Cutaneous, 

12 
Hydropericardium,  107 

etiology  of,  107 

pathology  of,  107 

symptoms  of,  107 

treatment  of,  107 
Hypertrophy  of  Heart,  49 

apex  beat  in,  50 

diagnosis  of,  49 

symptoms  of,  49 
Hysteria 

in     relation     to     Heart 
Disease,  161 
Icterus 

in     relation     to     Heart 
Disease,  16 
Incompetency,  Aortic,  114 

characteristics    of    mur- 
murs of,  114 

course  of,  115 

physical  signs  of,  114 

symptoms  of,  114 

treatment  of,  115 
Incompetency,  Mitral,  117 

diagnosis  of,  117 

symptoms  of,  117 
Incompetency,  Pulmonary, 
121 


INDEX. 


V. 


Incompetency,  Tricuspid, 

120 

diagnosis  of,  120 
symptoms  of,  120 
Inhibition  of  Heart 

as  aid  to  Diagnosis,  59 
Insanity    in     relation    to 

Heart  Disease,   161 
Jaundice,  12 
Kidneys,  20 
Liver  and  Spleen,  20 
Lungs,  13 
Edema  of,  14 
Hemorrhage  of,  14 
Lung  Gymnastics,  81 
Marasmus   in   relation   to 

Heart  Disease,  162 
Mediastino-Pericarditis, 
106 
etiology  of,  106 
symptoms  of,  106 
Mitral    Regurgitation,    36, 
117 
diagnosis  of,  117 
pulse  in,  54 
symptoms  of,  117 
Mitral  Stenosis,  12,  36,  118 
pulse  in,  54 
symptoms  of,  118 
Murmurs,  25,  31 
accidental,  36 
analectic  review  of,  38 
anemic,  45 

cardio-respiratory,  45 
character  of,  33 


diastolic,  2^,  S3 
hemic,  46 
inorganic, 

tabular  review  of,  40 
nature  of,  s^ 
obstructive,  25 

character  of,  33 
of  apprehension,  36 
of  gastric  origin,  S7 
organic,  31 

tabular  review  of,  40 
origin  of,  31 
Pericardial,  41 
Pleuro-pericardial,  45 
presystolic,  32,  23 
regurgitant,  25 

character  of,  33 
seat  of,  31 
significance  of,  30 
subclavian,  47 
systolic,  32,  33 
tabular    review    of    or- 
ganic   and    inorganic, 
40 
time  of,  32 
transmission  of,  32 
valvular  cardiac,  42 

tabular  review  of,  42 
venous  subclavian,  48 
Myocarditis,  125 
Nervous      Symptoms, 

Treatment  of,  89 
Nervous  System,  21 
Neurasthenia    in    relation 
to  Heart  Disease,  162 


INDEX. 


Neuroses  of  Heart,  128 

Etiology  of,  128 
Obstruction,  Aortic,  34 

pulse  in,  54 
Obstruction,  Mitral,  36 

pulse  in,  54 
Oertel,   Method   cf   in 
treatment  of  Heart  Dis- 
ease, 83 
Palpitation,  130 
Diagnosis  of,  130 
Treatment  of,  84,  130 
Paroxysmal    Tachycardia, 
132 
Diagnosis    of,    132 
Treatment  of,  132 
Pectoris,  Angina,  137 
Pericardial  Murmurs,  41 

Pleuro-,  45 
Pericarditis 
Acute  Plastic,  93 
Adherent,  106 
Chronic    Adhesive,    106 
Fibrinous,  93 
Mediastino,  106 
Purulent,  104 
with  effusion,  103 
Pericardium,  Affections 

of,  93 
Dropsy  of,   107 
Hemopericardium,  107 
Hydropericardium,  107 
Pericarditis,  93  to  106 
Pneumopericardium, 

108 


Pyo-pneumopericar- 
dium,  108 
Phthisis     in     relation    to 

Heart  Disease,  162 
Pleurisy 
in     relation     to     Heart 
Disease,  163 
Pleuro-pericardial  mur- 
murs, 45 
Pneumonia  (croupous) 
in     relation     to     Heart 
Disease,  163 
Pneumopericardium,  loB 
cause  of,  108 
symptoms  of,  108 
treatment  of,  108 
Precordial  Pain,  13 
Prevention  in  Diseases  of 

Heart,  65 
Pseudo-Angina,  140 
Pulmonary  Anemia,  46 
Pulse,  12 
character  of,  12 
Corrigan's,  54 
frequency,  54 
frequency     in     different 

ages,  164 
in    aortic    regurgitation, 

54 

in  aortic  stenosis,  54 

in    exudative    pericardi- 
tis, 55 

in  fever,  165 

in    mitral    insufficiency, 

54 
in  mitral  stenosis,  54 


INDEX. 


VII 


in  myocarditis,  55 

in  sexes,  165 

in  sleep,  165 

Influences  on,  165 

intermittent,  13 

irregular,  53 

rate,  164 

rhythm,  53 

tension  of,  53 

to  respiration,  165 

volume  of,  53 
Pyo-pneumopericardium, 

108 
Reflex,  Heart,  155 

Regurgitation    Aortic,    34, 
114 

Mitral,  117 

Pulmonary,  121 

Tricuspid,  120 

Renal    Complications, 

Treatment  of,.  90 

Resistance  Movements, 
176 

Rheumatism  in  relation  to 
Heart  Disease,  163 

Rotch  Sign,  97 

Schott  Treatment,  76 

Sphygmograph,"  54 

Spinal  Curvature  in  rela- 
tion to   Heart  Disease, 
163 

Spleen,   Liver  and,  20 

Sternocardia,  137 

Stenosis,  Aortic,  116 
Mitral,  118 
Pulmonary,  121 


Tricuspid,  121 
Stomach,  Acute  Dilatation 

of,    14 
Subclavian  Murmurs,  47 

venous-,  48 
Syphilis     in     relation     to 

Heart  Disease,  164 
Tachycardia     Paroxysmal, 
132 
Diagnosis  of,  132 
Treatment  of,  133 
Thromboses,  13 
Tonics,  Cardiac,  71 

Table  of,  T] 
Tonometer,  Gaertner,   147 
Treatment  of  Diseases  of 
Heart,  65 
by  Baths,  78 
by  Home  Exercise,  83 
by  Lung  Gymnastics,  81 
by  Method  of  Oertel,  83 
by  Resistance  Move- 
ments, 79 
by   Schott  Methods,   76 
by  Tonics,  71 
during   Compensation, 

68 
during  failure  of  com- 
pensation, 70 
Treatment    of    Individual 
Symptoms  in  Diseases 
of  Heart,  84 
Tricuspid  Regurgitation, 
120 
Diagnosis  of,    120 
Treatment  of,  120 


VIII. 


INDEX. 


Tricuspid  Stenosis,  121 

Mitral  Regurgitation, 

Tremors,  purring,  34. 

117 

Typhus,  Abdominal,  in  re- 

Mitral Stenosis,  118 

lation    to     Heart    Dis- 

Pulmonary Regurgita- 

ease, 158 

tion,  121 

Uric-Acid  Diathesis 

Pulmonary  Stenosis, 

in     relation     to     Heart 

121 

Disease,  164 

Tricuspid    Regurgita- 

Valvular Disease,  Chronic, 

tion,  120 

114 

Tricuspid  Stenosis,  121 

Aortic  Regurgitation, 

Valvular    Lesions,    effect 

114 

of  secondary,  34 

Aortic  Stenosis,  116 

Frequency  of,  27 

Combined,  122 

X-Rays  in  Cardiac  Diag- 

Diagnosis, 123 

nosis,  63 

DEC  1  s  m^ 


